Vesico Vaginal Fistula

VESICO-VAGINAL FISTULAE Dr. Awoyesuku A fistula is defined as an abnormal communication between 2 or more epithelial surfaces. Vesico-vaginal fistula (VVF) therefore is an abnormal communication between the genital tract (vagina, cervix, uterus) and the urinary tract (bladder, urethra and ureter). VVF is of public health importance because the social implications are far reaching. Due to the constant dribbling of urine and its pungent smell, they are usually ostracized and considered as outcast. EPIDERMIOLOGY The exact prevalence and incidence of VVF in Nigeria is not known. Harrison in 1985 gave a value of 0.35 of all births in Zaria. - It affects all ages but more in teenagers - It affects all parities but more in primips - Other factors include low social groups, illiteracy, low socio-economic groups especially rural dwellers Following a not too recent workshop by experts in Nigera, it was estimated that there are about 200,000 unrepaired fistulae in Nigeria and about 2 million worldwide. Estimated third world incidence is 1-2 per 1000 deliveries with about 50,000-100,000 new cases each year. AETIOLOGY/PATHOLOGY It may be congenital or acquired. (A) Congenital eg. Cases of ectopic ureter may discharge into the vagina. It is very rarely seen and therefore often overlooked. (B) Acquired 1. Obstetric: 90% 0f fistulae in the third world. (i). Negleted Obstructed Labour: Most common cause resulting from pressure necrosis which follows impaction of the fetal skull in the pelvis = trapping of soft tissues between fetal skull bones and maternal pelvis. Immediate effect = Dusty. By 2nd day = dark marking. 3-4th day = sloughing. Healing phase takes 10-12 weeks. Sepsis makes healing longer. (ii). Operative deliveries o Accidental trauma o Cesarean section esp. with lower segment repeat c/section o Forceps delivery eg. Forcible rotation with Kiellands o Breech extraction o Symphisiotomy = bladder injury o Traditional practices play a role in the aetiology of obstetric fistulae eg. Gishiri cut on the anterior vaginal wall, cicumcision esp. extreme forms can lead to tears (ant. vag. wall) or obstructed labour.

2. Surgical: > 70% in UK & developed world. It may result from compromise of blood supply = necrosis, or direct injury to the lower urinary tract. i. Hysterectomy ii. Colporrhaphy iii. Colposuspension. Cytoplasty, sling iv. Cervical stumpectomy 3. Radiation i. Pre-operative pelvic irradiation increases the risk of post-operative fistula development. ii. Irradiation itself may be a cause of fistula. Oblitirative endarteritis = Ischaemia. This also makes ordinary surgical repair have a high failure rate. 4. Malignancy i. Surgery or radiotherapy for pelvic malignancy has risk of fistula development ii. Tissue loss from malignant disease itself may result in genital tract fistular. 5. Miscellaneous i. Infections e.g. LGV, Schistosomiasis, TB, Actinomycosis, etc. ii. Catheter associated iii. Trauma (penetrating trauma) iv. Infection v. Coital Injury vi. Neglected pessary vii. Foreign body CLASSIFICATION First classification was by Benion Thomas (1945) - Juxta urethral - Midvaginal - Juxtacervical Krishner (1949) added – Combined Chasser Moir - Circumferential Lawson (1968) - Juxtaurethral - Midvaginal - Juxtacervical - Very large vault - Combined Hamilton/Nicholson Simple (healthy tissues, good access) – VVF, RVF, UrVF Difficult (tissue loss/scarring, impaired access) – High RVF, Vut. F N/B

Over 60% of fistulae in 3rd world are mid-vaginal, juxtacervical or massive (reflecting obstetric aetiology) while 50% of fistulae in UK are in vaginal vault (reflecting surgical aetiology). PRESENTATION 1. Continuous involuntary (total) urinary incontinence 2. Dysuria, if there is associated UTI 3. Excoriations 4. Loin pains 5. Cyclical haematuria Obstructed Labour Injury Complex An attempt to appreciate the total problems of the patient following obstructed labour, so that treatment will be geared towards the complete individual. 1. Urologic injury- VVF, Uvf, UrVF, UtVF, Complete Urethral loss, secondary hydronephrosis, stress incontinence, renal failure. 2. Gynaecologic- Amenorrhoea (psychologic, chemical), gynaetresia, cervical injury = incompetence/stenosis, PID with adhesions, secondary infertility. 3. Gastrointestinal tract- RVF, 3rd degree perineal tear, anal sphincter incompetence 4. Musculoskeletal system- Osteitis pubis, pressure sores 5. Central Nervous System- Foot drop (common peroneal nerve, L4,5 S1,2), Bladder dysfunction 6. Skin- Chronic ulceration 7. Social- Isolation, divorce, worsening poverty, malnutrition, suicide. INVESTIGATIONS 1. FBC: 2. URINE M/C/S:

Reduced Hb, increased WBC UTI is uncommon in VVF patients but should be sought after and treated before repair is undertaken. Pipette specimen is taken from the intraversical space. 3. SERUM E/U/Cr: Renal Function Test 4. IVU: To outline urinary tract and connections 5. HSG: To evaluate any amenorrhoea and exclude any Ut.VF 6. CYSTOSCOPY: To examine bladder mucosa, rule out calculi, see exact opening and its relationship to the ureteric orifices and bladder neck. 7. EUA & DYE TEST When the diagnosis is in doubt, this will help to confirm actual leackage being extraurethral and not urethral and the site of the leakage. In confirmed cases, EUA is done to determine o the number, site and size of the fistulae o the presence of scarring (fibrosis) o the best approach/position for repair and o the patency of the bladder. - Dye test is necessary to identify very small fistula and there location (triple dye test)

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A uretero-vaginal fistula produces a constant trickle of urine, but the bladder is still intact and will continue to function. The usual test is to instill a solution of suitable dye into the bladder. Cotton-wool in the vagina will not be stained if the fistula is ureteric. MANAGEMENT This is divided into initial management and definitive management. Initial Management Surgical fistula recognized within 24Hrs of the operation should be repaired immediately. Majority are recognized 5-14 days post-op and should be treated with continuous bladder drainage for 6-8weeks for spontaneous closure to occur. Obstetric fistulae after obstructed labour should be treated by continuous bladder drainage, combined with antibiotics to limit tissue damage from infection. Palliation/Skin care During the waiting period, the patient should use pads to soakurine and improve her social life. Due to the risk of developing ammoniacal dermatitis, a silicone barrier cream or Zinc oxide in castor oil should be used liberally. Nutrition They are often malnourished and anaemic and therefore improved nutrition is advocated. Haematinics should also be useful. Physiotherapy Management of a physiotherapist of foot drop/limb contracture for rehabilitation of the patients is essential. Surgery Options – Vaginal repair (route of choice) - Abdominal (Transvesical/transperitoneal) repair - Combined - Ureteric transplantation/ ileal conduit - Colpocleisis Principles of Vaginal Repair 1. Allow time for wound healing = 3 months for obstructed labour VVF = 6 months for radiation VVF = (? Recent advocates for earliar repair) 2. Pre-operatively - Time away from menses - Avoid OCP/steroids = impair healing - PCV, group & crossmatch blood if necessary 3. Anaesthesia - Local anaesthesia - Regional (spinal) – now being favoured - General anaesthesia – most people, to allow for adequate positioning 4. Exposure/lighting i. Position o Knee-chest position (genu-pectoral) o Trendelenburg o Exaggerated lithotomy

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Vaginal access o Labial stitch/Schuchardts incision o Specula Good lighting source – direct vision

5. Dissection/Mobilization - Catheterize urethra - Steady fistula, infilterate – adrenaline 1:200,000 sol  Define tissue plane  Reduce blood loss -

Excision of margin not necessary Make plans for possible graft Closure can be continuous or interrupted but should not be under tension Invert bladder margins, use 3/0 or 2/0 chromic catgut. Vicryl and Dexon are the best. It is better to use UR6 needles. Take wide bites – muscle and submucosa but avoid mucosa. Closure can be transversely or longitudinally Bladder is preferably closed in 2 layers but one may be okay Remember to do dye test at the end to ascertain adequate closure Pack the vagina with acriflavin dye or Vaseline gauze

POST-OPERATIVE MANAGEMENT 1. Good nursing care 2. High fluid intake - not less than 3-4L in 24Hrs 3. Monitor urine output – not less than 100-150mls per hour 4. Continuous bladder drainage x 14 days 5. Antibiotics administration is controversial. Give prophylactically if uncertain of sterile procedure 6. Analgesics 7. Vaginal pack can be removed in 24-48Hrs 8. Perineal toileting is essential 9. Ambulation Vs Restriction – if elderly, early ambulation will reduce the risk of DVT. 10. Discharge procedure  Bladder retraining/test of cure  No coitus for 6 months (3 months might be enough)  With subsequent pregnancy, mandatory ANC & C/S  Counselling on cause of injury and prevention. N/B What Is Cure: Closure of VVF, continence and re-integration into the society Combined VVF & RVF: You repair the VVF first then repair the RVF in 3 weeks. For a high RVF, you may need to do a colostomy.

COMPLICATIONS EARLY o Bleeding o Ureteric obstruction o Catheter not draining = use bladder syringe o Wound breakdown o Anaesthetic complication LATE o Stress incontinence o Gynaetresia o Mis-direction of menses PREVENTION It is absolutely preventable, especially with safe motherhood - Social equity for women - Antenatal care for all - Essential obstetrics for those at risk - Family planning for both couple - Effective child survival strategies CONCLUSION It is one social calamity too many. The cause is obstruction at all levels The pathology is misery and social alienation The cure is surgery The problem is enormous Prevention is the will.