The document discusses genitourinary fistulas, which are abnormal connections between urinary and genital organs. It defines different types of fistulas including vesicovaginal, ureterovaginal, and urethrovaginal. The most common type is the vesicovaginal fistula, which is often caused by prolonged obstructed labor leading to tissue necrosis. Symptoms include urinary incontinence. Diagnosis involves history, examination for openings, and dye tests to locate the fistula. Management includes prevention of obstetric injuries, surgery to close openings, and postoperative catheterization.

1. GENITO-URINARY
FISTULAS
Yashar Najiaghdam
M.D

2. Definition
 Abnormal communications between urinary
& genital organs.
 Remember 2 golden rules
 1st rule: urine may escape from
 ureter tube, uterus, cervix, vagina
 bladder tube, uterus, cervix, vagina
 urethra always vaginal.
 2nd rule in naming a fistula,
 Part of the urinary tract is 1st to be described

4. Varieties
1. Vesico-vaginal
2. Uretero-vaginal
3. Urethro-vaginal
4. Vesico-cervical
5. Uretero-cervical
6. Uretero-uterine

5. VESICOVAGINAL FISTULA
(The Commonest)

6. Aetiology
 Congenital: very rare.
 Traumatic fistula
 Obstetric trauma
 Necrotic obstetric fistula
 Traumatic obstetric fistula
 Surgical trauma
 Direct trauma
 Inflammatory disease
 Malignant neoplasms
 Radium necrosis

7. Necrotic Obstetric Fistula
 Prolonged compression of soft tissues between
head & brim of a narrow pelvis.
 → ischaemia, pressure necrosis & sloughing of
base of the bladder.
 Urethra is also often involved.
 Slough takes some days to separate
 → Incontinence develops 5-7 days after labour
 Such fistulae are often surrounded by dense
fibrosis

8. Traumatic Obstetric Fistula
 Direct injury to bladder wall by sharp
instrument (perforator or decapitation hook)
during a difficult labour
 Forceps rarely cause it
 Incontinence Appears immediately After
Labour

9. Traumatic Fistula
 Surgical trauma: Bladder may be injured
 during vaginal operation as anterior
colporrhaphy
 during abdominal operations as hysterectomy.
 Direct trauma: is a rare cause, but cases have
occurred as a result of impalement.

10. Other Causes
 Inflammatory disease: result from
 Bilharziasis of bladder
 Tuberculosis of bladder.
 A pelvic abscess may open into bladder & vagina
 Malignant neoplasms:
 As advanced carcinoma of cervix or of bladder, or
vagina
 By direct invasion of the wall and ulceration.
 Radium necrosis:
 Sloughing of the bladder
 As a complication of radium treatment used for cure of
malignant disease in pelvis

11. Symptoms
 Incontinence of urine
 Complete (large fistula) OR
 Partial (small or high fistula)
 DD: uretero-vaginal fistula.
 Symptoms of vulvitis:
 Pruritus, burning pain due to continuous
discharge of urine.
 Cystitis
 Due to ascending infection from vulva

12. Diagnosis
 History of incontinence following labour or operation.
 Several days after labour necrotic obstetric
fistula
 Immediately after difficult labour traumatic
fistula.
 Palpation of anterior vaginal wall:
 Large fistula Can be felt
 Small fistulas cannot be felt, but surrounding
fibrosis is usually palpable

13. Diagnosis
 Inspection of the anterior
vaginal wall
 In Sims’ position or left
lateral (semi-prone)
position
 With the use of Sims’
speculum.

14. Diagnosis
 For small and high fistula
 Dye test: Injection of methylene blue into
bladder by a catheter to outline the fistula while
anterior vaginal wall is inspected by use of
Sim’s speculum.
 DD: uretrovaginal fistula
 Sometimes a metal catheter or sound is passed
through the urethra to appear at the fistulous
opening.

15. Management
Prophylaxis:
 Antenatal:
 Diagnosis of abnormalities that possibly result in fistula
formation
 contracted pelvis
 malpresentations
 During labour
 Diagnose and deal with:
 prolonged labour
 contracted pelvis
 Malpresentations
 Risky operations should all be avoided
 high forceps
 forceps with incompletely dilated cervix
 risky destructive operations.

16. Management
 If injury to the bladder is discovered during a
difficult labour,
 Don’t suture the tear due to tissue oedema and
friability.
 fix rubber catheter for 10 days
 The tear may heal completely or be much smaller
 If the injury is detected some time after labour, as
in cases of necrotic fistulas,
 operations done except at least 3 months after delivery
to allow for maximum involution of the tissues.

17. Preoperative Preparation
 Treat vulvitis:
 Cover skin of the vulva, and inner thighs by a thick
layer of Vaseline, zinc oxide ointment or any bland
ointment, to prevent maceration of the skin by the
continuous discharge of urine.
 Renal function tests:
 Culture of urine,
 if pathogenic organisms are found, patient is given
urinary antiseptics until urine is sterile.

18. Methylene blue test
 to differentiate a small vesico-vaginal fistula from a
uretero-vaginal fistula.
 3 pieces of gauze are placed in the vagina
 200 cc of sterile fluid coloured with methylene blue is Injected
into the bladder
 The lowest piece of gauze is discarded as it is usually
stained during filling the bladder.
 If the middle or upper pieces stain → fistula is vesical
 If none of the pieces stain and the upper one is wet with
uncoloured urine → fistula is ureteric.
 If all are dry and unstained → excludes vesical or ureteric
fistula.

19. Methylene
blue
test

20. Cystoscopy
 Determine relation of the fistula to ureteric openings in
bladder
 Exclude multiple fistulas
 Reveal associated bladder pathology.
 Chromocystoscopy
 IV Injection of 4 c.c. of 0.4%
indigocarmine solution
 If kidney function is good →
Blue efflux from the ureter in 4
minutes.

21. Operation
flap-splitting operation, or dedoublement
 Circular incision around the fistula.
 The 2 short longitudinal cuts
upwards and downwards Long.
incision
 Through the thickness or the vagina
but not the bladder.
 → 2 flaps of vaginal wall. Circular
incision
 Free mobilization of the vaginal
Fistula
flaps from the bladder over a wide
area, at least 1.5 cms around the
fistula.

22. Operation
 The hole in bladder is then closed by 2
layers of interrupted sutures going through
muscle wall only & not piercing the mucous
membrane.
 The vagina is then closed by interrupted
sutures going through its whole thickness.
 A rubber catheter is fixed in the urethra
 Tight vaginal pack to prevent reactionary
haemorrhage.

24. The saucerisation operation
(Sim’s operation)
 Indicated
 If tissues are too adherent and fibrosed to do flap
splitting
 After failure of the flap splitting.
 Technique:
 Edge of the fistula is excised removing a wider part of
the vagina than of the muscle wall of the bladder
 Edges of both organs are simultaneously coapted
together by the use of nonabsorbable sutures
 Certain high fistulae are better treated by
abdominal (transperitoneal or transvesical) repair.

25. Postoperative Care
 Recumbent position
 The bladder should be constantly empty.
 Fluids (3 litres/day).
 Urinary antiseptics & antibiotics.
 Vaginal pack is removed 24 hours after operation.
 Catheter is removed after 10 days.
 After its removal the patient is instructed to void urine
 every two hours by day &
 every four hours by night,
 to avoid over-distension of bladder & disruption of suture line.

26. Subsequent Management
 Patient is instructed to
 avoid sexual intercourse for 3 months
 avoid pregnancy for 1 year
 Caesarean section is almost absolutely
indicated.

27. URETERO-VAGINAL FISTULA
 Cause:
 Injury to ureter during a gynaecological operation as
hysterectomy
 may develop following a difficult labour.
 It leads to incomplete incontinence
 Urine from affected ureter escapes from vagina while
bladder fills up & empties normally from other ureter
 It is always small & high up in vagina lateral to
cervix.
 Differentiated from a vesico-vaginal fistula by:
 by methylene blue test.
 Cystoscopy shows ureteric efflux on one side only.

28. Prophylaxis
 Ureteric injury can be avoided by
 pre-operative intravenous pyelography
 ureteric catheterization
 proper surgical technique.

29. Treatment
 Abdominal re-implantation of ureter into
bladder.
 If not possible, ureter is transplanted into
sigmoid colon.
 If kidney function is very poor on the
affected side → kidney can be sacrificed.

30. Kidney Function Tests
 Blood urea: Normally 20-40 mg%.
 Specific gravity of urine before and after water administration
(water concentration test):
 Normally high before, low after
 In chronic nephritis → low fixed S.G. of about 1010.
 Urea concentration test: Normally urea in urine' should be 2%
or over after administration of 15 grams of urea by mouth.
 Urea clearance test: It is a delicate test.
 It indicates the no. of cm3 of blood cleared of urea per minute
 Average = 70-120%
 < 50% → renal impairment.
 Intravenous pyelography.

31. Types Of Incontinence Of Urine
1. True incontinence genito-urinary fistula.
2. Stress (Sphincter) incontinence weakness of
Internal urethral sphincter.
3. Urgency incontinence severe inflammation
leading to marked irritation of bladder & so urge
to pass urine cannot be inhibited & some urine
will pass involuntary while patient is in her way to
W.C.
4. False incontinence retention with overflow
5. Nocturnal enuresis.

32. Causes Of Retention Of Urine
 Cause of urinary retention is an impacted
pelvic mass.
 Diagnosis is made clear by attention to
associated symptoms

33. Associated Conditions
Condition Diagnosis
Primary amenorrhea → Haematocolpos
Secondary amenorrhea →  Retroverted gravid uterus
Menorrhagia → Uterine fibroid
No menstrual upset → Ovarian or broad ligament tumour
Irregular bleeding → (1) threatened abortion from a retroverted
gravid uterus,
→ (2) pelvic haematocele
→ (3) pelvic abscess
Labour → Descent of the foetus to from a pelvic
tumour