1) Vesicovaginal fistula is an abnormal connection between the bladder and vagina, usually caused by prolonged obstructed labor without access to emergency obstetric care. It affects about 2 million women in developing countries. 2) Risk factors include hereditary narrow pelvis, early marriage, malnutrition, and low socioeconomic status. Fistulas are classified by location and size and can have physical, social, and psychological impacts. 3) Treatment involves catheterization, antibiotics, repair surgery to close the fistula tract, and postoperative catheter drainage and bladder training. Prevention relies on improved access to emergency obstetric care and socioeconomic development.

1. VESICOVAGINAL
FISTULA
GICHANA ELVIS

2. INTRODUCTION
Definition.
A VVF IT is an abnormal communication between the
epithelium of the urinary bladder and vagina.

3. Prevalence.
 Affects about 2 millions women, almost all in
developing countries, particularly in Africa and the
Indian sub-continent.

4. Risk factors
I. Hereditary contracted pelvis.
II. Early marriage-pelvis is not yet fully matured.
III. Malnutrition-pelvis tends to be of a small build.
IV. Poor access to emergency obstetric care.
V. Low socioeconomic status-women with VVF
come almost exclusively from poor families.
VI. Acquired contracted pelvis- accident/traumatic
, infections like polio or TB.

5. Classification
According to anatomicphysiologic location.
1:Not involving the closing mechanism
2:Involving the closing mechanism.
A:without(sub) total urethra involvement.
without circumferential defect.
with circumferential defect.
B:with(sub) total urethral involvement
without circumferential defect.
with circumferential defect.

6. 3.Miscellaneous, eg. Ureter and other
exceptional fistulas.
Further classification according to
size.
Small <2cm
Medium 2-3cm
Large 4-5cm
Extensive 6cm.

7. ETIOLOGY.
v 1)Direct trauma.
 During obstetric or gynecological
operations the bladder may be
accidentally injured.
 During c/section, hysterectomy,
forceps delivery, craniotomy.

8. Cont..
2)Obstetric injury
Prolong obstructed labor-ischemic necrosis.
Symptoms are seen 3-10 days post delivery.
3)neoplastic fistula.
Cancer of the cervix- stage IV.
Cancer of urinary bladder.
Cancer of the vagina.

9. Cont..
4)infections.
Granulomatous infections like TB
,Syphilis,Schistosomiasis
5)radiation.

10. Clinical features
Total urine incontinence
Urine -induced dermatitis,
ulcerations.
Pelvic bone pain
Foot drop, unsteady gait.

11. Clinical and social consequences of VVF.
Bladder prolapse, stone formation,
Loss of pelvic muscles tone.
Vaginitis, UTI,
Partial or complete loss of the labia
minora/ vagina, varying from loss of the
anterior vaginal wall to vagina stricture,
circular stenosis and even atresia.
Social and psychological pain
Possible future inability to become
pregnant.

12. History.
Is the leakage involuntary? Any urge to
micturate?
Antenatal review:
 Booking time, where? Who was
attending her?
 Any risk factor identified?
 How far is the clinic from her house?

13. Cont…
Labor:
 Onset of labor, when, where?
 At what time did the membrane
rupture?- possibility of infection.
 Duration of labor.
 Where did she delivered?

14. Cont..
Mode of delivery
Condition of the baby at delivery.
Condition of the mother.
Postdelivery
Was she catheterized?
H/o fever
When was the leakage first noticed?
Urge to micturate.
Weakness of the lower limbs.

15. Examinations
General:
Height- those less than 150cm are at increased
risk of cephalopelvic disproportion.
Gait: peripheral neuropathy due to compression
of nerve during prolong and obstructive labor.
CNS:-exam the lower limbs for tone, power,and
reflexes.

16. Pelvic examination
Inspection: ammoniac smell?
any presence of excoriation on the
vulva or perineum.
Digital examination:palpate the vaginal wall
to feel any defect or fistula margin.
Speculum:using Sims speculum, inspect
any presence of fistula, note the
size and position of fistula.

17. Management.
Immediate management of fresh fistula.
1)urethral catheterization:
40-60% of small fistula heal following 4-6 weeks
of catheterization.
2)antibiotics:
In case of an obstetric fistula antibiotic is not
needed since is due to pressure necrosis,
unless there is evidence of infection.
3)plenty of fluid, minimum of 6-8L/day.
4)oral hematenics and high proteins diet.

18. Cont..
5)Debridement of the slough/necrotic
tissues.
6)Early closure.

19. PREOPERATIVE MEASURES.
1)Plenty fluid; why?
 Prevents recurrent UTI.
 Prevents stone formation
 Minimizes ammoniac smell.
2)Hb levels, urinalysis.
3)Hematenics and high protein diet to speed up
recovery.
4)Preoperative EUA-controversial. Some surgeons
prefer doing at the same time of repair.

20. Time for repair.
Early repair:
No need of waiting for 3 months.
A fistula is a stigma with psychological
impact,it is for the patient to do early
repair.
Early repair has been reported to have
excellent success rate as to closure and to
continence and thus preventing the patien
from becoming an outcast.

21. Delayed repair:
No remaining necrotic tissues.
The wound has healed and well
vascularized.
Fistula has regressed to the smallest size.
Patient is in good condition for operation
and anesthesia.

22. Operation/fistula repair.
1)position:
Exaggerated lithotomy position with legs
flexed and slightly abducted in stirrup.
Knee chest position.
2)approach:
Transvaginal-recommended for almost all
repairs.

23. Cont..
Transabdominal-transvesical approach-when
the fistula margins are near the ureteric orifices
requiring a transvesical catheterization of the
ureters, mobilization of the bladder mucosa and
close without compromising the ureters.
Indicated also for large fistula with contracted
bladder.

24. 3) Fistula exposure
Adequate exposure is emphasized.
May need episiotomy uni-or bilateral or
Schurchardt incision in case of tight
vaginal outlet.
4)avoid the bladder mucosa and tension on
the bladder wall.
5)excision of the fistula tract.
6)repair East-westerly direction.

25. POSTOPERATIVE CARE
1)Encourage plenty of fluid.
2)indwelling catheter at least 2 weeks.
3) Input -output ,monitoring.
4)antibiotics-controversial
5)oral hematenics
6) Start ambulation,bladder training on day
2.

26. Cont..
7) Day 14:dye test.
If negative-remove catheter, encourage
to pass urine every 15 min.,avoid sex.
If positive-change catheter, retain for
another 4 weeks then repeat dye test.

27. Follow up:
Review her 2 weeks after removal of
catheter, then 1 month later, then 2-3
months, can resume sexual activities.
Enquire for leaking(incontinence)
Check for healing,stress incontinence.

28. POSTOPERATIVE COMPLICATIONS.
Early complications
Postoperative death-due to pulmonary
thromboembolism, urosepsis.
Blockage of the catheter.
Urine retention
Vaginal stenosis/atresia.

29. Late complications
Stress and/ urge incontinence
Overflow incontinence.
Fistula recurrence.
Bladder stone formations.

30. A successful fistula repair.
1)maintance of urine continence.
2)ability to hold urine up to 150-
160mls.
3)ability to perform sex and enjoy.
4)resumption of conception and
ability to bear a child.
Future deliveries.
Mode of delivery is mainly by
c/section.

31. PREVENTION.
Primary.
Prevention of prolong and obstructed
labor.
Education to women-ANC
attendance,hospital delivery.
Economy-alleviate poverty.
Socially-decision making power,abandon
early marriage.

32. Cont..
Promotion of good health
Improve infrastructures
Improve health facilities and personnel

33. Secondary prevention
Following obstructed labor:
Intervene - c/section.
Post delivery bladder catheterization.
Antibiotics.
Tertiary prevention and rehabilitation.
Fistula has already occurred. Aimed at
providing good
environment for either spontaneous healing or
successful repair.
Measures for early treatment
Psychotherapy.

34. Delivery situation in the country:
45% is home delivery
55% is done in the health institutions
which include:
Dispensaries,maternity homes,health
centres,district hospitals,reginal
hospitals, and consultants hospitals.

35. cont..
Trained personnels are not enough or
lacking in many health centers.
The infrastructure is poor

36. THANKS