This presentation covers the all basic knowledge

1. Vesicovaginal Fistula
Dr. Muhammad Junaid Qasim
Postgraduate Resident Surgical 01

2. Case Presentation
 My patient Bakhtawar Bibi 40 Years old resident of Chishtian admitted to surgical
Unit 01 with complaint of per urethral leakage of
blood --- 03 Months
stool and urine --- 01 Month
 My patient had pelvic surgery (hysterectomy) three years back she was alright
since then only 3 Months ago she started having continuous bleeding from
urethra. The color of blood is fresh red. It also occurs during urination associated
with pain in the lower abdomen which is partially relieved by the pain killers.
 From the last one month she is also passing flatus and stool per urethra.
 She also complains of burning micturition.

3.  Past Medical History: Non Significant
 Past Surgical History: Pelvic surgery 3 years back
 Personal History: Good sleep and appetite
 Family History: Non Significant
 Socioeconomic: Low socioeconomic status

4. Examination
Upon General Physical Examination A female of middle age, average
built and height lying on bed fully conscious and actively answering my
questions
She had an obvious palor indicative of anemia
On PV Examination there was a large 7`7 cm rent in the anterior vaginal
wall, 6`3 cm rent in left posterior vaginal wall. A cauliflower shaped
growth was also observed on cervical lips and right lateral wall of vagina.
On PR Examination No rectal rent was felt

5. Investigations
Baselines:
Hb 3.4
TLC 5300
PLT count 564000
Ultrasonography:
Moderate hydronephrosis and hydroureter noted in Right side, Uterus
was missing , hetrogenous Ill defined area(50`32mm) seen in pelvis

6. CT Abdomen and Pelvis with Contrast
An ill defined aggressive looking hetrogenously enhancing mass of about 3.8`
2.4 cm seen at the region of cervical stump causing luminal narrowing in
consistent with the residual recurrent mass. Fat plane between tumor and
surrounding gut loops is indistinct.
A defect of 11.4mm is seen in posterior bladder wall through
which the contrast is seen passing into the vaginal stump. Air
specks are also seen in urinary bladder and vaginal stump. Surrounding
excessive fat stranding is noted. Multiple inflammatory lymph nodes are seen in
pelvic region along bilateral iliac vessels and presacral space, one such
measuring 25mm in short axis along left iliac vessels

7. Cervix Biopsy
High grade squamous intraepithelial lesion

8. Relevant Clinical
Anatomy

9. UROGYNAECOLOGICAL FISTULA
Definition Of Fistula : Fistula represents an extra- anatomical
(pathological) communication between two or more body cavities
covered by their own epithelia; the communicating tract Is also
epithelized.
Urogenital Fistula : Any Abnormal communication between
URINARY and GENITAL TRACT with INVOLUNTARY ESCAPE OF URINE into
genital tract

10. Types or Urinary Tract Fistulae
UROGYNECOLOGIC FISTULAE
VESICO V
AGINAL FISTULA(VVF)
VESICO UTERINE FISTULA
URETERO VAGINALFISTULA
URETHRO VAGINALFISTULA
UROENTERIC FISTUALE
UROVASCULAR FISTUALE
OTHER URINARY FISTULAE

11. Types Of Genito Urinary Fistula
Bladder
Vesico Vaginal
Vesico Uterine
Vesico Cervical
Vesico Urethro-
Vaginal
Ureter
UreteroVaginal
UreteroUterine
UreteroCervical
Urethra
UrethroVaginal

12. 1 • VesicoVaginal Fistula
2 • Vesico Urethro Vaginal
3 • UrethroVaginal
4 • Vesico Cervical
5
• Uretero Vaginal
6 • Vesico Uterine

13. Genito Urinary
Fistula
Acquired
Obstetrical Gynaecological Accidental
Congenital

14. Aetiology
Congenital Malformation
Aberrant ureter and persisting urogenital Sinus
Mostly associated with other urinary tract abnormalities
Accidents
RTA-> Crush injuries to pelvis -> Bone Fragments -> Perforation of
Bladder/Urethra
Avulsion of Urethra
Fall on a pointed Object

15. Obstetrical Causes
MCC of Genito Urinary Fistula – in Developing Countries (>75%)
But in Developed Countries (5-15%)
Ischemic Necrotic Obstretic Fistula
Prologed Obstructed Labour
CPD and Malpresentation -> Trigone of Bladder crushed between pubic symphysis ->
Ischaemic tissue necrosis -> sloughing -> genitourinary fistula
Slough seperated after 7 to 8 days -> gives away -> thus incontinence develops after 7
to 8 days after delivery
Most common site of ischaemic injury -> Juxta urethral region

16. Obstructed Labour
Trigone of Bladder crushed
between Pubic Symphysis
and Presenting Part
Compression Ischaemia
Necrosis
Fistula Formation on 7th –10th
day

17. OBSTRETICAL CAUSES
TRAUMATIC FISTULA
Instrumental Vaginal Delivery
Destructive operations ; Foreceps delivery ( esp – Kielland freceps)
Bony Spicule of fetal skull in Craniotomy
Caesarean Section
At risk – Pt with prev LSCS
Bladder caught in Suture – Ischaemia – Fistula
Uterine vessel Ligation - UretersAt Risk of Injury
Rupture of Scar of Prev LSCS – implicate adherent bladder base
In Such cases of Direct Traumatic Injury – FistulaAnd Incontinence
follows Soon after Delivery

18. GYNAECOLOGICAL CAUSES
OPERATIVE INJURY
In Developed countries – accounts for 70% of Fistulas
URETER –At risk in TOTAL HYSTERECTOMY esp, RADICAL
HYSTRECTOMY , Removal of Broad Ligament Tumors
Risk of Ureteral Injuries – 7 TIMES more in Laparoscopic Procedures
URETHRA– Threatened during –ANTERIOR COLPORRAPHY &
SLING OPERATION

19. Post Surgical Fistula
Unrecognized bladder injury during difficult hysterectomy Or Cesarean Or
Surgery involving Anterior Vaginal Wall
1. 2.
Post Hystrectomy Fistula – Located above the interureteric
ridge
Vaginal Cuff Suture–
Incorporated into
Bladder
Tissue Ischaemia And
Necrosis
Fistula
Overvigorous
blunt dissection
of bladder from
uterus
Result in Tear in
Post Bladder
wall or
D evascularisatio
n

20. MALIGNANCY -
Advanced Carcinoma of Cervix , Vagina or Bladder -> Direct spread -> Fistula
FOrmation
RADIOTHERAPY
Excessive, misapplied and even well apllied irradiation for Pelvic Malignancy esp,
CACERVIX causes -> Endarteritis Obliterans -> Ischaemic Necrosis -> Fistula
It is a LATE COMPLICATION -> Takes 1 – 2 yrs to form a fistula
INFECTIVE
Vaginal Foreign Bodies, Forgotten and Retained Pessaries
Chronic Granulomatous Lesions – GENITALTB, LGV, SCHISTOSOMIASIS,
ACTINOMYCOSIS – rare causes of Fistula

21. Vesico Vaginal Fistula(VVF)
• VVF is the most common fistula (>75%)
• Injury to bladder at the time of gynaecological, urological or
pelvic surgery.
• Patients present with incontinence following surgery or pelvic
intervention that may present with immidiate or delayed onset of
urinary leakage from the vagina , abdominal pain , distention
prolonged bowel ileus , suprapubic pain and hamturia.

22. Classification of VVF
SIMPLE
Fistula < 2 to 3 cm in size
SUPRATRIGONAL (near the cuff)
No h/o Radtion or Malignancy
Vaginal Length – Normal
Healthy tissue
Good access
COMPLICATED
Fistula > 3 c m in size
Fistula distant from Cuff Or Trigone
involved
H/o previous Radiatherapy &
Malignancy + Vaginal Length –
Shortened
A/w Scarring
Involving Urethra, Vesical Neck , Ureter,
Intestinal Fistula
Previous Unsuccesful attempt at Repairs

23. I. High Fistula
2. Vault (Vesico Uterine)
1. Juxtacervical
II.Mid Vaginal Fistula
III.Low Fistula
1. Bladder Neck – Urethra Intact
2. Urethral Involvement – Segmental ( partial Bladder
Neck Loss)
3. Complete Bladder Neck Loss – Circumferential fistula
IV.Urethro Vaginal Fistula
Small fistula Below Bladder Neck Incompetent
V. Massive Vaginal Fistula
Encompasses all three Levels & includes one or both
ureters in addition

25. Evaluation OF VVF
HISTORY
GENERAL AND GENITAL EXAMINA
TION
CONFIRMATION OF DIAGNOSIS
RADIOLOGICAL EVALUATION
CYSTOSCOPIC EVALUATION

26. History
VVF present with TRUE INCONTINENCE –
Continous Escape of Urine per vagina
No urge to Void Urine
Large Fistula – May not pass Urine at all. Continous Leakage of Urine per Vagina
Small Fistula – Escape of Urine in certain Position & also Can pass urine normally
Timing of Leakage of Urine:
Following surgical Injury – First Post operative day
Obstetric Fistula – 7th to 10th day
Urethral Fistula situated higher up – May present as SUI (Stress urinary Incontinence)
Vesicocervical & Vesicouterine Fistulae – May hold urine at Uterine Isthmus & remain
Continent
Menouria – cyclical hematuria at time of menstruation
Pruritis vuvlvae, Perineal skin irritation due to Constant Wetness, Recurrent Cystitis
Pain - uncommon finding in VVF unless there is considerable skin irritation or the VVF
occurred as a result of radiation therapy.
Urine
D ermatit
is

27. History
Age and Socio Economic Status of Women
Previous Gynaecological Surgery/ Radiotherapy
Previous history of Prolonged Labour/ Obstructed Labour/ trauma during
childbirth
Time of Occurrence
History of Urine leakage
Timing of Leakage, amount of leakage
Voiding per urethra apart from leakage
Any attempt of previous repair of Fistula

28. EXAMINATION
General Examination
Per Abdomen Examination – Surgical Scars
Vulval Inspection
Escape of watery discharge per vagina of
ammoniacal smell is characteristic
Sodden texture & excoriation of Vulval Skin
Varying degrees of perineal Tears may be present
Per Speculum Examination
Sim's Position & Sim's Speculum
Any pooling of fluid in the vagina
Site , Size, number of Fistula
Assess quality of surrounding tissue ; Tissue mobility
Bladder mucosa maybe visibly prolapsed
through a big fistula
Sims Speculum Sims Position

29. Per Vaginal Examination
Palpate Anterior and posterior Vaginal Wall
Assessment of tissue mobility, site, size,
determination of degree of tissue
inflammation, edema and infection,
Large VVF seen at the apex of the vagina.
VVF seen as reddish pink bladder mucosa
prolapsing into vagina.
A. Large VVF- Bladder
Mucosa Visible with
ureteral catheters visible
entering ureteral orifices
B. & C. Large VVF with
Rectovaginal Fistula due
to obstructed labour.

30. Confirmation Of Diagnosis
Dye Test
Methylene Blue introduced into Bladder by Catheter – dye visible coming through
opening
3 Swab test / Tampon test of Moir
Double Dye Test
a.)Oral Phenazoprydine b.) Bladder filled with blue tinted Solution.
c.) Tampon inserted per vagina
Presence of BLUE staining – VVF or UrethroVaginal Fistula
Presence of RED Staining(pyridium) – UreteroVaginal Fistula
Metal Catheter passed through External meatus into bladder when comes out
through fistula into vagina – Confirms VVF and patency of urethra
Examination Under Anaesthesia

31. Juxta-Cervical Fistula
Mid vaginal Fistula Bladder Mucosa
Prolapsed through
Vagina
At Junction of Urethra
and Bladder
Examination

32. Algorithm for the diagnosis of VVF

33. 3 Swab Test
3 separate Sponge swabs in Vagina .Bladder
filled with Methylene Blue. Patient made to do
exertional maneuvers. Swab removed after 10
mins
1. Bluish Discoloration of Topmost or Middle Swab
----> VesicoVaginal Fistula
2. UpperMost Swab Getting Wet with URINE , but
no Bluish Discolouration
----> UreteroVaginal Fistula
3. Bluish Discolouration of Lower Most Swab , But
UPPER 2 swabs remain DRY
----> UrethroVaginal Fistula

34. CYS TOSCOPY
An endoscopic examination should be performed in
patients for whom a suspicion of VVF is present
Immature fistulae may appear as areas of localized
bullous edema without distinct ostia.
Mature fistulae may have smooth margins with
variably sized ostia.
A guidewire or ureteral catheter may be placed
through the working channel of the cystoscope and into
the fistula tract.
Visualization of the wire in the vagina confirms the
exact location of the VVF on both the bladder and
genital sides.
V
B

35. Radiological/Imaging Studies
Radiological studies are recommended prior to surgical repair of a
VVF to fully assess the defect and exclude the presence of multiple
fistulae
Intravenous Urography – For the diagnosis of UreteroVaginal
Fistula
Retrograde Pyelography – If IVP Negative and high suspicion of
UreteroVaginal Fistula
Cystography – Done in Complex Fistula
HSG ( HysteroSalphingography) - For diagnosis of VesicoUterine
Fistula when patient presents with symptoms of Menouria
USG, CT, MRI – Done for complex Fistulae

36. Radiological Studies
A Cystogram and/or voiding cystourethrogram
(VCUG) and an upper tract study should be
performed in patients being evaluated for a VVF.
On filling bladder with Contrast , contrast begins to
opacify the vagina, confirming VVF .
VVFs are often best seen in the Lateral
Projection in which the bladder and vagina are not
superimposed
CT should be performed with only intravenous
contrast, OR, alternatively, a CT cystogram can be
performed to isolate the bladder
Delayed CT visualization of contrast within the
vagina is considered highly suspicious for VVF in the
majority of cases

37. Computed tomography (CT) scan of vesicovaginal fistula (VVF).A,After
intravenous administration of the contrast agent, there is high-density
material in both the bladder and vagina consistent with a VVF.

38. Laboratory Studies
Vaginal Vault Fluid Colletion
Tested for Urea, CreatinineAnd Potassium
To determine likelyhood of VVF
Rule out Vaginitis
Urine C/S
Biopsy of Fistula tract/ Urine Cytology – If Suspicious OF
MALIGNANCY

39. PREVENTION
Primary Prevention
GoodAntenatal Care
Awareness and Education
Watchful Progress of Labor
Trained BirthAttendants
Availability and Utilization Of Emergency Obstetric Care Units
Secondary Prevention
Early Recognition of CPD & Prevention of OBSTRUCTED LABOUR
LSCS in indicated Cases
Avoidance of Difficult Foreceps and destructive procedures
PROLONGED CATHETER DRAINAGE IN Prolonged Or Obstructed Labour

40. Prevention Of Surgical Causes of Fistula
Adequate Exposure during Surgery
Minimize bleeding and hematoma formation
Dissection in Correct Planes
Wide mobilization of Bladder
Intra operative retrograde filling of Bladder
Cystourethroscopy during surgery to confirm no injury to bladder

41. MANAGEMENT
CONSERVATIVE MANAGEMENT
MEDICALTHERAPY
SURGICALTHERAPY
NON SURGICAL INTERVENTION

42. Algorithm for management of vesicovaginal fistula (VVF)

43. CONSERVATIVE MANAGEMENT
Indications
Simple Fistulae
<2 to 3 cm Size of fistula in Newly diagnosed VVF
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 Fistulae may resolve Spontaneously
If fistula Decrease in size --> drainage for additional 2-3 weeks
If no Improvement within 30 days --> Needs Surgery

44. Medical Management
Estrogen Replacement Therapy
Optimize tissue vascularization and healing in Post-Menopausal patient
Local Estrogen Vaginal Cream
2 to 4 g placed Pervaginally at bedtime once a week for 4-6 weeks in those who are hypoestrogenic
Acidification of Urine
To diminish risk of cystitits,bladder calculi formation
Vitamin c 500mg once TDS
Antibiotics
Urised
Combination of antiseptics (methanamine, methylene blue, phenyl salicylate , benzoic acid) and parasympathetics
(atropine sulfate, hyoscyamine sulfate)
Sitz Bath
Barrier Ointment
Zinc Oxide or Vaseline application to treat perineal and ammonical dermatitis

45. NON SURGICAL INTERVENTION
ELECTROCAUTERY FULGURATION
Fistula Small in size
VaginalAnd Cystoscopic route --> Fulguration --> Foley's catheter kept in
place for 2-3 weeks
FIBRIN GLUE
Useful and safe for intractable fistula
LASER WELDING and Nd YAG Laser
Fulguration and transcatheter for 3 weeks

47. Surgical Management
Timing Of Repair
Dictum is that best time of repair of fistula is at its first closure during index
surgery
Obstetric Fistula – 3-6 months following Delivery
Surgical Fistula
If recognized within 48 hours – immediate repair
Otherwise repaired after 10-12 weeks
Radiation Fistula –After 12 months

48. Route of Repair
Depends upon access to fistula site, mobility of Vagina and surgeon expertise

50. Surgical Techniques
VaginalApproach
LatzkoApproach
Flap Splitting Method
Saucerization
AbdominalApproach

51. Latzko Technique
A. Retraction including ring retractor, vaginal speculum, and Foley catheter
in the VVF tract.AFoley catheter is seen in the VVF tract providing traction
on the vaginal cuff.
B. Mobilization of anterior vaginal wall flap. Lateral flaps are developed as
well, thereby isolating the VVF tract.
C. Mobilization of posterior vaginal wall flap.
D. Initial layer of closure is performed without excising the edges of the fistula
tract.
E. The perivesical fascia is closed with Lembert-type sutures. This line of
closure is perpendicular to the initial suture line.
F. The vaginal wall flaps are advanced to avoid overlapping suture lines.

52. Latzko
Technique
Latzko technique for
a closure of a simple
posthysterectomy
vesicovaginal fistula

53. FLAP SPLITTING TECHNIQUE
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.

54. g
Flap Splittin
Technique

55. 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

56. Abdominal Approach Indications
High Inaccessible Fistula
Multiple Fistulae
Involvement of UTERUS OR BOWEL
Need For Ureteral Reimplantation
Complex Fistula
Associated with Pelvic Pathology

57. Suprapubic Intraperitoneal Approach
The patient is positioned in a low lithotomy position with access to the vagina in the sterile operative
field. Alower midline incision is carried out.
The bladder is opened vertically, and the cystotomy is extended down to the opening of the VVF.
As the dissection proceeds distally, stay sutures placed on the bladder edges greatly assist in retraction.
With the bladder having been bivalved down to the level of the VVF, the VVF tract is excised, and
the dissection is continued beyond the fistula tract to develop the vesicovaginal space
The vagina is carefully dissected and separated from the bladder for a distance of 2 to 3 cm beyond the
VVF vagina is closed with a running absorbable suture.
Interpositional flap of greater omentum is to be used, it is mobilized and then secured 1 to 2 cm
distally beyond the excised VVF tract.
The bladder is then closed in several layers. A suprapubic tube and urethral catheter are usually left
for postoperative drainage.

58. Suprapubic
Intraperitoneal
Approach

59. Transvesical Approach
A.In this approach, the bladder is opened through a vertical
cystotomy but is not bivalved down to the VVF tract.
B.From a transvesical approach, the VVF tract is circumscribed and
excised transvesically.
C. The vaginal edges are then carefully mobilized from the bladder.
D. The vagina and bladder are closed sequentially

60. Pedicle Interposition Grafts
For Repair of Big Fistula, Post Irradiation Fistula
AIM
To support Fistula Repair
To fill dead space
To bring in new blood supply to area of repair
Grafts
Martius Graft - Labial fat and bulbocavernous Muscle
Gracilis
Omental graft
Rectus abdominis
Peritoneal flap graft

61. Laparascopic Repair of VVF

63. Post Operative Management
Continous Bladder irrigation for 10-14 days
Maintain output 100ml/hr
Antimicrobials
Plenty of Fluids for continuous bladder drainage
Watch for Bladder Block
DischargeAdvice
To pass urine frequently
Avoid intercourse for atleast 3 months
To defer pregnancy for atleast 1 yr
Successful repair should have abdominal delivery
If repair fails, local repair should be reattempted after 3 months

64. Summary and take home message
• VVF is the most common (75%) of all the genitourinary and pelvic wall fistulas
• It is the most common complication of pelvis and perineum surgery
• VVF presents with true incontinence
• CT IV Contrast is the most important radiological investigation to diagnose
complex fistulas
• Definitive management includes surgical repair which includes vaginal(for
uncomplicated fistulas) as well as abdominal approaches( for large complicated
fistulas
• Adequate exposure in surgery and dissection in correct planes can prevent
fistula formation

65. References
• CAMPBELL-WALSH-WEIN HANDBOOK OF UROLOGY 1st EDITION
• SMITH AND TANAGHO’S GENERAL UROLOGY 18th EDITION
• OXFORD HANDBOOK OF UROLOGY 4th EDITION
• GOOGLE.COM.

66. THANKYOU