(21) Genito-urinary Fistula
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GENITO-URINARY FISTULAS
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
Varieties 1. 2. 3. 4. 5. 6.
Vesico-vaginal Uretero-vaginal Urethro-vaginal Vesico-cervical Uretero-cervical Uretero-uterine
VESICOVAGINAL FISTULA (The Commonest)
Aetiology
Congenital: very rare. Traumatic fistula Obstetric trauma Necrotic obstetric fistula Traumatic obstetric fistula Surgical trauma Direct trauma Inflammatory disease Malignant neoplasms Radium necrosis
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
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
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.
Other Causes
Inflammatory disease: result from
Malignant neoplasms:
Bilharziasis of bladder Tuberculosis of bladder. A pelvic abscess may open into bladder & vagina 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
Symptoms
Incontinence of urine
Complete (large fistula) OR Partial (small or high fistula)
Symptoms of vulvitis:
DD: uretero-vaginal fistula.
Pruritus, burning pain due to continuous discharge of urine.
Cystitis
Due to ascending infection from vulva
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
Diagnosis
Inspection of the anterior vaginal wall In Sims’ position or left lateral (semi-prone) position With the use of Sims’ speculum.
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.
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.
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.
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.
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.
Methylene blue test
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.
Operation
flap-splitting operation, or dedoublement
Circular incision around the fistula. The 2 short longitudinal cuts upwards and downwards Through the thickness or the vagina but not the bladder. → 2 flaps of vaginal wall. Free mobilization of the vaginal flaps from the bladder over a wide area, at least 1.5 cms around the fistula.
Long. incision
Circular incision Fistula
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.
The saucerisation operation (Sim’s operation)
Indicated
Technique:
If tissues are too adherent and fibrosed to do flap splitting After failure of the flap splitting. 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.
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.
Subsequent Management
Patient is instructed to
avoid sexual intercourse for 3 months avoid pregnancy for 1 year
Caesarean section is almost absolutely indicated.
URETERO-VAGINAL FISTULA
Cause:
It leads to incomplete incontinence
Injury to ureter during a gynaecological operation as hysterectomy may develop following a difficult labour. 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.
Prophylaxis
Ureteric injury can be avoided by
pre-operative intravenous pyelography ureteric catheterization proper surgical technique.
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.
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.
Types Of Incontinence Of Urine 1. 2. 3.
4. 5.
True incontinence → genito-urinary fistula. Stress (Sphincter) incontinence → weakness of Internal urethral sphincter. 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. False incontinence → retention with overflow Nocturnal enuresis.
Causes Of Retention Of Urine
Cause of urinary retention is an impacted pelvic mass. Diagnosis is made clear by attention to associated symptoms
Associated Conditions Condition Primary amenorrhea
Diagnosis → 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
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
Varieties 1. 2. 3. 4. 5. 6.
Vesico-vaginal Uretero-vaginal Urethro-vaginal Vesico-cervical Uretero-cervical Uretero-uterine
VESICOVAGINAL FISTULA (The Commonest)
Aetiology
Congenital: very rare. Traumatic fistula Obstetric trauma Necrotic obstetric fistula Traumatic obstetric fistula Surgical trauma Direct trauma Inflammatory disease Malignant neoplasms Radium necrosis
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
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
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.
Other Causes
Inflammatory disease: result from
Malignant neoplasms:
Bilharziasis of bladder Tuberculosis of bladder. A pelvic abscess may open into bladder & vagina 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
Symptoms
Incontinence of urine
Complete (large fistula) OR Partial (small or high fistula)
Symptoms of vulvitis:
DD: uretero-vaginal fistula.
Pruritus, burning pain due to continuous discharge of urine.
Cystitis
Due to ascending infection from vulva
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
Diagnosis
Inspection of the anterior vaginal wall In Sims’ position or left lateral (semi-prone) position With the use of Sims’ speculum.
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.
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.
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.
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.
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.
Methylene blue test
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.
Operation
flap-splitting operation, or dedoublement
Circular incision around the fistula. The 2 short longitudinal cuts upwards and downwards Through the thickness or the vagina but not the bladder. → 2 flaps of vaginal wall. Free mobilization of the vaginal flaps from the bladder over a wide area, at least 1.5 cms around the fistula.
Long. incision
Circular incision Fistula
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.
The saucerisation operation (Sim’s operation)
Indicated
Technique:
If tissues are too adherent and fibrosed to do flap splitting After failure of the flap splitting. 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.
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.
Subsequent Management
Patient is instructed to
avoid sexual intercourse for 3 months avoid pregnancy for 1 year
Caesarean section is almost absolutely indicated.
URETERO-VAGINAL FISTULA
Cause:
It leads to incomplete incontinence
Injury to ureter during a gynaecological operation as hysterectomy may develop following a difficult labour. 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.
Prophylaxis
Ureteric injury can be avoided by
pre-operative intravenous pyelography ureteric catheterization proper surgical technique.
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.
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.
Types Of Incontinence Of Urine 1. 2. 3.
4. 5.
True incontinence → genito-urinary fistula. Stress (Sphincter) incontinence → weakness of Internal urethral sphincter. 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. False incontinence → retention with overflow Nocturnal enuresis.
Causes Of Retention Of Urine
Cause of urinary retention is an impacted pelvic mass. Diagnosis is made clear by attention to associated symptoms
Associated Conditions Condition Primary amenorrhea
Diagnosis → 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
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