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Vesico Vaginal Fistula

Vesico Vaginal Fistula

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03/18/2014

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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 \u2013 Combined
Chasser Moir
- Circumferential
Lawson (1968)

- Juxtaurethral
- Midvaginal
- Juxtacervical

- Very large vault
- Combined
Hamilton/Nicholson
Simple (healthy tissues, good access)
\u2013 VVF, RVF, UrVF
Difficult (tissue loss/scarring, impaired access) \u2013 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:
Reduced Hb, increased WBC
2. URINE M/C/S:

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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