Remember 2 golden rules 1st rule: urine may escape from ureter tube, uterus, cervix, vaginabladder tube, uterus, cervix, vaginaurethra always vaginal. 2nd rule in naming a fistula,Part of the urinary tract is 1st to be described
In developing countries obstructed labour is a common problem as women are economically underpriviledged, illiterate, married early, poor accesss to family planning and medical services, teenage pregnancy, antenatal careAndroid pelvis, malnutrition, orthopedic disorders like rickets, hydrocephalus causes dystocia
Lower end of the ureter, bladder base and urethra may be directly injured by instruments
incidence of VVF after hysterectomy is approximately one in 1,300 surgeries- MOST COMMON WITH LAP HYSTER TAH VAGINAL HYSTERECTOMYCan be damaged at pelvic brim during division and ligature of infundibulopelvic ligamentLower ureter – is at risk during vaginal hysterectomy and prolapse repair operation
Malignancy and radiation accounts for about 5% of total cases in developed countried.Point A- 2 cm cephalic and 2 cm lateral to external os, 7000-8000 cgyPoint B- 2 cm cephalic and 5 cm lateral in same plane 2000cGy
Gynaecologic fistula are generally classified as simple and complicated..and they have important implication in surgical approach and prognosis. Eg simple VVF have uncomplicated surgical approach with good prognosis
Obstetric fistulae are usually categorized according to their cause, complexity and site of obstruction.Posthysterectomy fistula are usually supratrigonal medial to both ureteric orifices and within the vaginal vaultObstetric causes fistula are amore distal, larger and are more commonly associated with urethral injury.Juxtacervical (close to the cervix)- communication is between the supratrigonal region of bladder and the vagina (vault fistula)Mid vaginal- between trigone of bladder and vaginaJuxtaurethral- between neck of the bladder and vagina. Sometimes include upper urethaSubsymphyisial- circumferential loss of tissue in the region of bladder neck and urethra. Fistula margin is fixed to the bladder.
Detailed obstetric history include- parity, duration of labour, vaginal or caserean, instrumental vaginal, weight of the baby, where was baby delieverd- hospital or home?Poor young women there is increased incidence of CPD and VVF due to early age of marriage, teenage pregnancy, malnutrition, pelvic bone immaturity, reduced birth canal size before the age of 18Prolonged labouresp 2nd stage can lead to VVF; History of any obstructed labour should be extractedPPH and spesis are associated with poor wound healing and make patient prone for developing VVFTiming- continous, walking, lying down, stress incontinence, Amount of leakage depend on size and site of fistulaDetailed obstetric history include- parity, duration of labour, vaginal or caserean, instrumental vaginal, weight of the baby, where was baby delieverd- hospital or home?Poor young women there is increased incidence of CPD and VVF due to early age of marriage, teenage pregnancy, malnutrition, pelvic bone immaturity, reduced birth canal size before the age of 18Prolonged labouresp 2nd stage can lead to VVF; History of any obstructed labour should be extractedPPH and spesis are associated with poor wound healing and make patient prone for developing VVFTiming- continous, walking, lying down, stress incontinence, Amount of leakage depend on size and site of fistula
General- ht, wt, bmi, pallor, signs of malnutritionSim’s position- pt lie on left side with left leg straight and right leg flexed at hip and knee vagina becomes ballooned up due to negative suction and give better view of anterior vaginal wallPV digital examination gives better idea than speculum examination for the assessment of all features seen by speculum.
Urine c/s if positive should be treated prior to surgery
Cystoscopic examination is used to determine the number, location and proximity to ureteric orifices, to identify and remove abnormal entities such as calculi or suture in bladderCystoscopic examination using co2 gas- vagina is filled with water or NACL, the infusion of gas through the urethra with cystoscope produces air bubbled in the vaginal fluid at the site of UGF
Ensure high fluid intake so as to reduce the risk of infection
In 3 months allow general condition to improve and local tissues are likely to be free from infectionFurther delay likely to produce more fibrosis
Perineal and vulval dermatitis and local infection treated with zinc oxide ointment, glycerine, vaselineUrinary infection should be treated
JACK KNIFE- PATIENT is in prone position with hips abducted and flexed and table jack knifed
JACK KNIFE- PATIENT is in prone position with hips abducted and flexed and table jack knifed
Flap-splitting closure of a simple vesicovaginalfistula. A: Ureters have been catheterized. An incision through the vaginal epithelium is made circumferentially around the fistula. B: The vaginal epithelium is widely mobilized from the bladder. The scarred fistula tract should be excised. C: A continuous (or interrupted) delayed-absorbable suture inverts the mucosa into the bladder. D: A second suture line is placed in the musculofascial layer to reinforce the first. Vaginal epithelium is trimmed and approximated.
It is an excellent procedure for correcting small posthysterectomy fistulae at the vaginal apex.The Latzko operation is a partial colpocleisis involving the upper 2 to 3 cm of vagina that surrounds the fistulaSuitable for fistula which is small and high in vaginaLatzko technique for a closure of a simple posthysterectomyvesicovaginalfistula. A: A circumferential incision is made around the fistula. The fistula is not excised. B: The vaginal epithelium is mobilized approximately 2 cm from the fistula. C: Delayed-absorbable interrupted mattress sutures are placed parallel to the edge of the fistula tract to invert it into the bladder. D: One or two additional rows of suture approximate the musculofascial layer of the bladder. E: The vaginal epithelium is closed transversely with interrupted delayed-absorbable sutures
Transvesical – fixed and high fistula in vaultTransperitoneal- vesicouterine fistula, ureteric fistulaCombined- is used when fistula margin are close to the ureteral orifices.
Rectum is protected by peritoneum of POD in upper 1/3rd, by perineal body in lower 1/3rd , and by sacral hollow in middle 1/3rd. Hence if the sacrum is flat, during obstructed labour—the compression effect produces pressure necrosis, sloughing and fistula
Heavy irradiation of any type causes ishchemic necrosis of bowel and lead to fistula with stricture 3months to several years after treatment.Malignant rectovaginal fistula nearly always means primary disease in the bowel.Rectum may be opened during TAH or any operation which volve puncture, incision or dissection on the posteriod vaginal wall and fornix. If injury not identified and repaired --. Usually results in fistula
Proctosigmoidoscopic examination for integrity of intestinal mucosa
Methylene blue is inserted into rectum which can be seen coming out through vagina.Contrast studies
Contrast studies are used to define sigmoidovaginal fistula and fistula with primary bowel diseaseProctosigmoidoscopy is done to ensure that the integrity of intestinal mucosa is normal
involves a circular incision about the fistulous opening (Fig. 40.14). With traction on the vaginal wall and countertraction applied to the edge of the fistulous tract, the vagina is separated from the underlying rectal wall with sharp dissection, and this proceeds circumferentially (Fig. 40.15). This wide mobilization permits later approximation of the fresh injury free of tensionthe entire fistulous tract is excised to include a small rim of the rectal mucosa (Fig. 40.16), converting the fistula to a fresh injury
With the surgeon's nondominant index finger lifting and supporting the anterior rectal wall, the initial sutures are placed extramucosally, including a portion of the muscularis and submucosainitial suture line begins and is extended a full 5 to 8 mm above and below the site of the fistulous tract to assure complete closure. A second layer P.1018(Fig. 40.18) begins 5 mm above the previously closed suture line and extends 5 mm distal to the fistulous closure, inverting the initial suture line into the rectum, and no sutures are located within the rectal lumen.
Genital tract fistulas main
GENITAL TRACT FISTULASDr. Shaheen HokabajC. S. I, Mysore
DEFINITIONDEFINITION• A FISTULA is an abnormal communicationbetween two or more epithelial surfaces• GENITAL TRACT FISTULA is an abnormalcommunication between epithelial surfaces ofUrinary Genital TractIntestine Genital TractSkin Genital Tract
GENITOURINARY FISTULA• Is an abnormal communication betweenurinary and genital tract with involuntaryescape of urine into the genital tract• 2-7 Million women affected worldwide• 0.2-1% of gynecologic admission
AETIOLOGY• CONGENITAL MALFORMATION– Aberrant ureter and persisting urogenital sinus– Mostly associated with other urinary tractabnormalities• ACCIDENTS– Road traffic accident Crush injuries to thepelvis bone fragments can causeperforation of the bladder or urethra– Avulsion of urethra– Fall on pointed object
• OBSTETRICAL CAUSESIn the developing countries- commonest causeaccounts for 80-90% of cases (developed 5-15%)– ISCHEMIC NECROTIC OBSTETRIC FISTULAProlonged Obstructed labour- CPD and malpresentation trigone of bladder isnipped between presenting part and pubicsymphysis ischemic tissue necrosis sloughing genitourinary fistula- Slough take some days to separate thusincontinence develops 7-10 days after delivery
Obstructed laborTrigone of bladder isnipped in between pubicsymphysis and presentingPartCompression ischemiaNecrosisFistula formation7-10th postnatal day
Fetal deathFistula formationFecal incontinence Urinary incontinenceComplex urological injuryVaginal scarring and stenosisSecondary infertilityChronic skin irritation,Offensive odoursStigmatizationIsolation and loss of social supportDivorce or separationWorsening povertyWorsening malnutritionObstructed Labor Injury Complex
• OBSTETRICAL CAUSES- TRAUMATIC FISTULA– Instrumental Vaginal delivery such as destructiveoperations or forceps specially with kielland.• Injury inflicted by bony spicule of the fetal skull in craniotomyoperation– In Caesarean section• At risk in patient with previous LSCS• if bladder is caught in the suture can cause ischemia leadingto fistula formation- Ligation of main branch of uterine vessels in case ofhemorrhage due to lateral extension of transverse incision inLSCS Ureters are at risk of injury- Rupture of scar of previous LSCS can implicate adherentbladder baseIn such direct traumatic injury, fistula and incontinencefollows soon after delivery
• GYNAECOLOGICAL CAUSESOPERATIVE INJURY– In developed countries it accounts for 70% of fistulas– In nearly all gynaecological operations one or otherpart of the urinary tract is in danger– URETER- is at risk in total hysterectomy especiallyradical hysterectomy, removal of broad ligamenttumours- Risk of ureteral injury was seven times greater withlaparoscopic procedures than with open procedures- URETHRA- is threatened during anterior colporrhaphyand sling operation
Post surgical fistula - PathophysiologyUnrecognized bladder injury during difficult hysterectomy or cesareanOr surgery involving anterior vaginal wallPost hysterectomy fistula – located above the interuretericridgeOvervigorous blunt dissectionof bladder from the uterusResult in tear in Post bladder wall ordevascularisationTissue ischemia, necrosisFistulaVaginal cuff suture –Incorporated into bladder1. 2.
• MALIGNANCY-– Advanced carcinoma of cervix, vagina or bladder mayproduce fistula by direct spread• RADIOTHERAPY– Excessive, misapplied and even well applied irradiationfor pelvic malignancy esp carcinoma of cervix causesendarteritis obliterans ischaemic necrosis fistula– Late complication- takes 1-2 years to produce such fistula• INFECTIVE– Vaginal foreign bodies, forgotten and retained pessaries– Chronic granulomatous lesions such as genitaltuberculosis, LGV, schistosomiasis, actinomycosis – rarecauses of fistula
VESICOVAGINAL FISTULA(The Commonest)VVF is an abnormal communication between bladder and vagina and the urine escapes intothe vagina resulting in true incontinence
HISTORICAL PERSPECTIVE• The first record of a VVF is found in the writings ofancient Hindu medicine, the Vedas and Upavedas.• Avicenna, a Persian physician, was the first knownwriter to mention the occurrence of a VVF and alsorecognized the association between such a lesion andlabor• James Marion Sims, 1852- Father of surgery of VVF firstpublished his method for the surgical treatment of VVFusing a transvaginal approach• Trendelenburg in 1888 successfully performed thetransabdominal VVF repair.
Classification of VVF• Simple- Fistula <2-3 cm in size- Supratrigonal(near the cuff)- No history of radiationor pelvic malignancy- Vaginal length isnormal- Healthy tissue- Good access• Complicated- Fistula >3 cm in size- Fistula distant from cuff orhas trigonal involved- H/o previous radiotherapyand Pelvic malignancy ispresent- Vaginal length is shortened- Associated with scarring- Involving urethra, vesicalneck, ureter, intestinalfistula- Previous unsuccessfulattempt at repairs
Classification according to the site offistulaI. High fistula1. Juxtacervical 2. Vault (vesicouterine)II. Mid Vaginal fistulaIII. Low fistulaa. Bladder neck- Urethra intactb. Urethral involvement- segmental(Partial bladder necklossc. Complete bladder neck loss- circumferential fistulaIV. Urethrovaginal fistulaA small fistula below the bladder neck is incompetentV. Massive vaginal fistula encompasses all three levels andoften includes one or both ureters in addition
Classification according to the size• Small <2 cm• Medium 2-3 cm• Large 4-5 cm• Extensive >6 cm
EVALUATION OF VVF• History• General and Genital Examination• Confirmation of diagnosis• Radiological Evaluation• Cystoscopic Evaluation
HISTORY• VVF is usually presented with continuous escape of urineper vaginum ( true Incontinence)- CLASSIC SYMPTOM.• Patient got no urge to void urine• Small fistula- escape of urine occur in certain position andcan also pass urine normally• Leakage of urine following surgical injury occurs from thefirst postoperative day• Obstetrical fistula- symptoms take 7-14 days to appear• Urethral fistula situated high up- may present with stressincontinence• Vesicocervical and vesicouterine fistulae- may hold urine atthe level of uterine isthmus and remain continent• Menouria- cyclical hematuria at the time of menstruation ispresent• Pruritis vulvae, perineal skin irritation, fungal infection dueto constant wetness
HISTORY• Age and socioeconomic status of women• Previous gynaecological surgery/radiotherapy• Previous history of prolonged labour/ traumaduring childbirthIf previous delivery is suspected as cause detailedobstetric history should be gathered.• Time of occurrence• History of urine leakage• Timing of leakage, amount of leakage• Voiding per urethra apart from the leakage• Any leakage of faeces, gas leakage• Any attempt of previous repair of fistula
EXAMINATION• General Examination• Per Abdomen examination- surgical scars• Vulval Inspection– Escape of watery discharge per vaginam ofammoniacal smell is characteristic– Sodden and excoriation of the vulval skin– Varying degree of perineal tears may be present• Per Speculum Examination– Sim’s position and Sim’s Speculum– Any pooling of fluid in the vagina– Site, size, number of fistula– Assess quality of surrounding tissue; tissue mobility– Bladder mucosa may be visibly prolapsed through abig fistula
• Tiny fistula-– is evidenced by apuckered area of vaginalmucosa– when women coughswhile lying in simsposition bubbles are seencoming through tinyfistula• Per Vaginal examination– Palpate anterior andposterior vaginal wall– Gives better idea of fistula– Assessment of tissuemobility, size, site,determination of thedegree of tissueinflammation, edema andinfectionSims positionSimsspeculum
CONFIRMATION OF DIAGNOSIS• Dye testMethylene blue introduced into bladder by a catheter dye willbe seen coming through the opening• Three Swab test /Tampon test of Moir• Double dye testGive patient oral phenazoyridine, fill the bladder with the bluetinted solution and insert a tampon.Presence of blue staining suggest- VVF or urethrovaginal fistulaRed staining (pyridium) suggest ureterovaginal fistula• Metal catheter passed through external urethral meatusinto the bladder when comes out through the fistula invagina confirms VVF and patency of urethra• Examination under anaesthesia
Midvaginal obstetric fistula- metal catheter is passed through it
3 swab test (Vaginal Gauze test)• Three separate sponge swabs are placed intothe vagina one above the another• The bladder is then filled with a colouredagent such as methylene blue through arubber catheter, and patient asked to do someexertional manuevers and then the swabs areremoved after 10 mins.
Result of 3 swab test1. Discolouration of topmostor middle swab vesicovaginal fistula2. Uppermost swab wettingbut not discolouration Ureterovaginal fistula3. Discolouration of lower mostswab but upper two swabsremain dry Urethrovaginal fistula123
Laboratory studies• Vaginal vault fluid collection– Tested for urea, creatinine and potassium– To determine likelihood of diagnosis of VVF– Rule out vaginitis• Urine C/S• Biopsy of fistula tract/ urine cytology ifsuspicious of malignancy
Imaging studies• Radiologic studies are recommended prior to surgicalrepair of a vesicovaginal fistula to fully assess thedefect and exclude the presence of multiple fistulae• Intravenous urography- for the diagnosis ofureterovaginal fistula• Retrograde pyelography- if IVP negative and highsuspicion of ureterovaginal fistula• Cystography- done in complex fistula• Sinography (fistulography)- for intestinogenital fistula• HSG- for diagnosis of vesicouterine fistula when patientpresents with symptoms of menouria• Ultrasound, CT,MRI- done for evaluation of complexfistulae
Diagnostic procedures for VVF• Cystoscopic Examination• Cystoscopic Examination using CO2 gas (FLAT TIREsign)• Combined Vaginoscopy- cystoscopy– Transillumination of the bladder or vagina by turningoff the vaginal or bladder light allows for easieridentification in difficult cases• Colour Doppler ultrasonography with contrastmedia of the urinary bladder in cases wherecystoscopic evaluation is equivocal• Fistulograms- indicated if conservative therapy isplanned.
Cystogram showing extravasation of dyefrom bladder into vaginal canalCystoscopic view of fistula
PREVENTIONOBSTETRIC FISTULA• PRIMORDIAL PREVENTION– Girl’s Education– Women’s Empowerment– Increase the age of marriage– Nutritious diet since childhood• PRIMARY PREVENTION– Availability of family planning method services– Strategy to make motherhood safer should be followed– Good antenatal care– Watchful progress of labour– Trained birth attendants– Transportation and emergency obstetric care
PREVENTION• SECONDARY PREVENTION– Early recognition of CPD and prevention of obstructedlabour– LSCS in indicated cases– Avoidance of difficult forceps and destructiveoperations– Prolonged Catheter drainage in prolonged orobstructed labour.RADIATION FISTULA• Proper dose and technique of irradiation• Packing of the vagina• Midline block
If you suspect fistula is going to form followingobstructed labour or destructive operation– Insert an in dwelling catheter and start continuousclosed drainage– Ensure a high fluid intake– Mobilize her early, always keeping the bag belowher bladder– After 7-10 days examine her anterior vaginal wall inSim’s position with speculum• If her bladder is still bruised or necrotic– Leave her catheter in and remove only whenhealthy tissue is seen in next examination
PREVENTIONSURGICAL FISTULA• Adequate exposure during surgery• Minimize bleeding and hematomaformation• Dissection in correct planes• Wide mobilisation of the bladder• Intra op retrograde filling of bladder• Cystourethroscopy during surgery
MANAGEMENT• CONSERVATIVE MANAGEMENT• MEDICAL THERAPY• SURGICAL THERAPY• NONSURGICAL INTERVENTION
CONSERVATIVE MANAGEMENT• Indications– Simple fistulae– <1 cm in size– Diagnosed within 7 days of index surgery– Unrelated to carcinoma or radiation• Continuous bladder drainage– By transurethral or suprapubic catheter– Duration- upto 30 days• Small fistula may resolve spontaneously• If fistula decrease in size drainage for additional 2-3 weeks• If no improvement in 30 days will need surgery
MEDICAL MANAGEMENT• Estrogen Replacement Therapy– Optimize tissue vascularization and healing in postmenopausalpatient• Local Estrogen Vaginal Cream– 2-4 gm placed pervaginally at bed time once a week for 4-6 weeksin those who are hypoestrogenic• Acidification of urine– To diminish risk of cystitis, bladder calculi formation– Vitamin C 500mg orally TDS• Antibiotics• Urised– Combination of antiseptics (methenamine, methylene blue,phenyl salicylate, benzoic acid) and parasympatholytics (atropinesulfate, hyoscyamine sulfate)• Sitz bath• Barrier ointment such as zinc oxide or vaseline application– In treatment of perineal and ammoniacal dermatitis
NON SURGICAL INTERVENTION• ELECTROCAUTERY FULGURATION– Fistula small in size (pinhole openings– Vaginal and cystoscopic route fulguration foley’s catheter placement for 2-3 weeks• FIBRIN GLUE– useful and safe for intractable fistula• LASER WELDING with Nd YAG laser– Fulguration and transurethral catheter for 3 weeks
SURGICAL MANAGEMENTPRINCIPLES• Timing of repair• Route of repair• Suitable equipment and illumination• Adequate exposure, patient positioning• Excision of fistulous tract (controversial)• Use of suitable suture material• Sufficient post operative bladder drainage
TIMING OF REPAIR• Dictum is that best time to repair fistula is atits first closure during index surgery.• Obstetric fistula- 3 months following delievery• Surgical fistula– if recognized within 48 hours- immediate repair– Otherwise repaired after 10-12 weeks• Radiation fistula- after 12 months
PREOPERATIVE CARE• Improvement of general condition• Continuous bladder drainage• Antibiotics• Estrogen cream• Topical creams for ammoniacal dermatitis
PREOPERATIVE ASSESSMENT• Local assessment of the fistula best done 1-3 daysbefore the repair- fistula status• Urine routine and microscopy• Urine culture and sensitivity• Cystocopy• Urethroscopy• Voiding cystourethrogram depending on• Intravenous urogram cause• Retrograde pyelogram• Urodynamic studies
ROUTE OF REPAIRDepends upon access to the fistula site, mobilityof the vagina and surgeon expertiseSITE APPROACHLOW FISTULAUrethralJuxtaurethralVAGINALCIRCUMFERENTIALLOSS OF BLADDER NECKCOMBINEDABDOMINOVAGINALMIDVAGINAL FISTULA TRANSVAGINALHIGH VAGINAL FISTULAPost hysterectomy or juxtacervicalABDOMINAL ORVAGINAL APPROACH
PATIENT POSITION• Dorsal lithotomy position with StandardTrendelenburg position• Sim’s position• Knee chest position• Jack knife positionInstruments should be fine tipped and longhandledSuture materialVicryl 2-0 suture material- bladder and vaginaPolydioxanone 4-0 - ureter
Jack knife positionDorsal lithotomy position withStandard trendelenburgSim’s position
General concepts of surgery• First attempt is the best attempt• Tension free closure• Water tight closure• Non overlapping suture lines• Use of interpositional grafts• Use of delayed absorbable suture material
• For repair of big fistula, postirradiation fistula• AIMTo support fistula repairTo fill dead spaceTo bring in new blood supply to area of repair• GRAFTS– Martius graft – Labial fat and bulbocavernous muscle– Gracilis– Omental graft– Rectus abdominis– Peritoneal flap graftPedicle interposition grafts
POSTOPERATIVE MANAGEMENT• Continuous bladder drainage 10-14 days• Maintain output at 100ml / hr• Antimicrobials• Plenty of fluids for continuous bladder drainage• Watch for any bladder block, fluid balanceDISCHARGE ADVICE:To pass urine frequentlyAvoid intercourse for at least 3 monthsTo defer pregnancy for at least 1 yearSuccessful repair should have abdominal deliveryIf repair fails, local repair should be reattempted after3 months
CRITERIA FOR SUCCESSFUL REPAIR(WHO 2006)CRITERIA GOOD PROGNOSIS UNCERTAIN PROGNOSISNO. OF FISTULA Single MultipleSITE VVF RVF, MIXED (RVF +VVF)SIZE <4 cm >4 cmVAGINAL SCARRING Absent PresentTISSUE LOSS Minimal ExtensiveURETER INVOLVEMENT Draining into bladder Draining into vaginaURETHRAL INVOLVEMENT Absent PresentCIRCUMFERENTIAL DEFECT Absent Present
DEFINITION• Abnormal communication between therectum and vagina with involuntary escape offlatus and/or feces into the vagina resulting infecal incontinence• Socially disabling condition
ETIOLOGYI. CONGENITALIncomplete partition of cloacaII. ACQUIRED• OBSTETRICAL– Incomplete healing or disruption of primary repaired orunrepaired recent complete perineal tear (commonestcause)– Obstructed labour– Difficult forceps delievery– Midline episiotomy– Instrumental injury during destructive operations– Develop immediately or 7-10 days after delievery(common)
• GYNAECOLOGICAL– Following incomplete healing or repair of old CPT– Operative injury- in operations like perineorraphy,repair of enterocele, posterior colpotomy to drainthe pelvic abscess, vaginal reconstructive surgery– Accidental Trauma- fall on a sharp pointed object– Malignancy- of vagina, cervix or bowel– Radiation– Infections –LGV , tuberculosis– Inflammatory bowel disease• Crohn’s disease of lower bowel and rectum > UC– Diverticulitis of sigmoid colon abscessformation burst into vagina
EVALUATIONClinical presentation– Involuntary escape of flatus and/or feces into the vagina– If fistula is small incontinence of flatus and loose stoolonly but not of hard stool– Foul smelling vaginal discharge with periodic uncontrolledescape of gas– Appear immediately or 7-10 days after deliveryRectovaginal examination– Identification of fistula number, site and size– Assessment of surrounding tissue of fistula– Contraction of puborectalis muscle and external analsphincter should be assessed– Perineal body is examined
Confirmation– Thin Probe is passed from the vagina through thefistulous tract into the rectum/anal canal– Methylene blue dye test– Air bubble seen in saline filled vagina afterinsertion of air into rectum through Foley’scatheter– Examination underanaesthesia
INVESTIGATIONS• Barium enema• Gastrogaffin Enema• Barium meal• Barium follow through• Sigmoidoscopy and proctoscopy with biopsy• CT scans• MRI• Ultrasound
CLASSIFICATION• Based on anatomical location of vaginal openingLow - vaginal opening near the posterior fourchette)Mid (from the level of the cervix to just superior to theposterior fourchette)High (the fistula is in the area of the posterior fornix).• Simple vs Complex– Simple are small (<2.5cm),low, due to trauma /infection– Complex are large, high,due to IBD, radiation, malignancy
TREATMENT• PREVENTIVE– Good intranatal care– Identification of perineal tear and its effectiverepair– Identification of rectal injury during surgeries andits effective and appropriate surgery
DEFINITIVE SURGERY• ROUTE: transvaginal, transanal, and abdominalapproaches– Determining factors: cause of the fistula, its location andaccessibility, and the status of the anal sphincter.– Fistula located in lower part of anal canal transvaginalroute in lithotomy position– Fistula located high up in apex of vagina abdominalapproach• TIMING: Wait 8-12 weeks before surgical interventionto allow surrounding inflammation to resolvecompletely• Preoperative Mechanical Bowel preparation• On morning of operation, Tap water enema until it isclear
Low rectovaginal fistula repairtechniqueSmall rectovaginal fistula withproposed line of initial incisionExcision of fistulous tract.
Extramucosal placement ofsutures in wall of anterioranal canal
The lower portions of the puborectalis muscle and the external anal sphincter are approximatedto add a third layer in the closure which helps to reconstitute the anterior rectal wall
Fistula converted to fourth degreeperineal tear.• If fistula is so close to the external anal sphincter that theclosure is difficultBridge of skin,sphincter andperineal body isdividedExcision of fistulous tractMobilization of posterior vaginal wall fromAnterior anal canalConverting RVF into 4th degree perineal tear12
3 4 5Reconstructedperineal bodywith subcuticularapproximationof skin of perineumReanastomosis of retractedexternal anal sphincter inEnd to end fashionwith surgeons left indexfinger in the anal canalTwo layer reconstruction of anal canalInitial layer- approximating mucosaof anal canalSecond layer approximating retractedend of IAS inverting initial layer
SUMMARY• A thoughtful preoperative workup with extensivepreoperative counseling regarding expectations andpossible outcomes is crucial for the ultimate satisfactionof the patient• Mechanical bowel preparation, perioperative antibioticprophylaxis, and attention to postoperative diet andstool consistency management are important• Rectovaginal fistula repair requires thorough surgicalplanning, careful attention to detail, and a meticulousoperative technique to provide the patient with optimalresults.• Rectovaginal fistula repair requires careful attention tosharp dissection, gentle tissue handling, widemobilization, meticulous hemostasis, and a tension-freeclosure.