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6

URINARY PROBLEMS IN
GYNAECOLOGY & TRAUMATIC FISTULAS

QUESTIONS
DE
1.

Most common cause of vesicovaginal fistula in


India is :
[AIIMS Nov. 02]

b. Cystoscopy

a. Gynae surgery

d. IVP

b. Irradiation

c. Urine culture
5.

c. Obstructed labour
d. Trauma
2.

Kamla, a 48 years old lady underwent


hysterectomy. On the seventh day, she developed
fever, burning micturation and continuous urinary
dribbling. She can also pass urine voluntarily. The
diagnosis is :
[AIIMS May 01]

a. Triple Swab test


b. Urine culture
c. Cystoscopy
d. IVP

a. Vesico vaginal fistula


6.

b. Urge incontinence

3.

Post partum VVF is best repaired after :

c. Stress incontinence

a. 6 weeks

d. Uretero-vaginal fistula

b. 8 weeks

[AI 04]

d. 6 months
7.

Chassar Moir technique is used in :

b. Midstream clean catch

a. VVF

c. Foleys catheterisation

b. Stress incontinence

d. Sterile speculum

c. Urethrocoele

Most useful investigation for VVF is:


a. Three swab test

[AI 10]

[AIIMS 87]

c. 3 months

The most appropriate method for collecting urine


for culture in case of vesicovaginal fistula is :
a. Suprapubic needle aspiration

4.

A 52 year old lady with VVF after abdominal


hysterectomy is not responding to conservative
management, most useful important next
[AI 2010]
investigation is:

d. Enterocoele

[AMU 05]

Urinary Problems in Gynaecology & Traumatic Fistulas


8.

9.

In a case of incontinence of urine, dye filled into


the urinary bladder does not stain the pad in the
vagina, yet the pad is soaked with clear urine. Most
likely diagnosis is :
[UPSC 00]
a. VVF
b. Uretero vaginal fistula
c. Urinary stress incontinence
d. Urethero vaginal fistula
Commonest site of obstetric injury leading to
uretero vaginal fistula :
[PGI 96]

15.

a. Atrophic and stenotic urethra


b. Lumber disc prolapse
c. Injury to bladder neck
d. Injury to hypogastric plexi
16.

b. Bladder Training

b. Vaginal vault

c. Electrical stimulation

c. Ureteric tunnel

d. Vaginal cone/weights

d. Below cardinal ligament where uterine artery crosses

11.

12.

Ureter is identified at operation by :


a. Rich arterial plexus
b. Peristaltic movement
c. Relation to lumber plexus
d. Accompanied by renal vein

14.

17.

[AIIMS 96]

In women with ureterovaginal fistula, the following


statements are true except :
[J & K 05]
a. Produces free fluid in abdominal cavity
b. 40% heals spontaneously
c. It is associated with hydronephrosis on affected side
d. Should be repaired as soon as diagnosed on IVP
A case of obstructed labour which was delivered
by caesarian section complains of cyclical passage
of menstrual blood in urine. Which is the most likely
site of fistula :
[AI 04]

Kellys plication operation is done in :


a. Stress incontinence

[PGI June 05]

b. Vault prolapse
c. Rectal prolapse
d. Uterine prolapse
e. Cervical incontinence
18:

Bonneys test demonstratesa. Stress urinary incontinence


b. Urge incontinence
c. Overflow
d. All of the above

19.

Version I.
Which of the following surgeries for stress
incontinence has highest success rate: [AI 2011]
a. Bursch colposuspension

a. Uretherovaginal

b. Pereyra sling

b. Vesico-vaginal

c. Kellys stitch

c. Vesico-uterine

d. Tension free vaginal tape (TVT)

d. Uretero-uterine
13.

The recommended non surgical treatment of stress


incontinence is:
[AI 09]
a. Pelvic Floor Muscle Exercises

a. Infundibulo pelvic ligament

10.

A 55 year old woman has recurrent urinary retention


after a hysterectomy done for a huge fibroid. The
most likely cause is :
[AI 03]

19.

Version II.

Multipara With Lscs, Presents With Cyclical


Hematuria, Diagnosis can be:
[PGI Dec 08]

Among the surgeries to correct SUI, the long-term


success rate is maximum with:[All India 2002, 2011]

a. VVF

a. Burchs colposupension

b. UVF

b. Stameys repair

c. Bladder Endometriosis

c. Kellys stitch

d. Ca. Cervix

d. Aldridge surgery

Patient of Rectovaginal fistula should be initially


treated with :
[AI 05]

20.

Treatment of genuine stress incontinence :


a. Anterior colporrhaphy

a. Colostomy

b. Posterior colporrhaphy

b. Primary repair

c. Colposuspension

c. Colporrhaphy

d. Pelvic floor exercise

d. Anterior resection

e. Sling operation

[PGI Dec. 04]

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Self Assessment & Review Gynaecology


21.

The disadvantage of Marshall marchetti -Krantz


procedure compared with other surgical
alternatives for treatment of stress urinary
incontinence includes-

23.

a. Retroverted uterus

a. Urinary retention

b. Pelvic hematocoele

b. Increased incidence of urinary tract infections

c. Impacted Cervical Fibroid


d. Carcinoma Cervix

c. High failure rate


d. Osteitis pubis
22.

A woman treated for infertility, presents with 6 week


amenorrhea with urinary retention. The most likely
[AI 00]
etiology is :

24.

a. May present congenitally

Cause(s) of retention of urine in reproductive age


group :
[PGI Dec. 00]

c. It is a cause of infertility
d. Causes menorrhagia

b. Retroverted gravid uterus


d. Severe UTI
e. Posterior urethral valve

e. Associated with PID


25.

Urinary bacterial count is < 105/ml is insignificant in


all except :
[AIIMS June 00]
a. Pregnancy
b. Healthy ambulatory male
c. In a setting of antibiotics treatment
d. Mid stream clean catch sample.

104

[PGI Dec. 01]

b. Associated with endometriosis

a. Cervical fibroid
c. Unilateral hydronephrosis

Which is true regarding retroverted uterus :

Urinary Problems in Gynaecology & Traumatic Fistulas

CHAPTER
AT A
GLANCE
DE

Urinary Fistulas
Vesicovaginal Fistula

Uretero Vaginal Fistula

M/C

VVF is the m/c urinary fistula

Etiology

In Developing countries -Obstructed labor


It is due to ischaemic necrosis so
develops 3-5days after delivery.
In Developed countries- pelvic surgery

Hysterectomy
Maximum risk is with
wertheims hysterectomy

Chief Complaint

Continuous dribbling of urine from vagina


+ No normal urge for urination

Continous dribbling of urine


from vagina + normal urge for
urination

Methylene blue
3 swab test
(M oirs test)

Middle cotton plug is wet with dye and


urine (blue in colour)

Uppermost cotton plug is wet


with urine but not with dye.
Other 2 cotton swabs are dry

Investigation
Of choice

Cystoscopy

Mgt of
Choice- Surgery

Technique- Layer technique/ Latzko


repair/ chassar moir technique

Boari Flap technique

-Time of surgery- If it is due to


obstructed labour repair should be done
after 3 months.(so that infection and
inflammation subside)

As early as possible

Urethro Vaginal Fistula

No continuous leakage
but when patient
urinates, urine leaks
from urethra and vagina.
Lower most cotton plug is
wet with dye, other two
are dry.

Dye test with indigo carmine


demonstrates
urinary
extravasation and identifies
the location of injury +
Cystoscopy

If it is due to surgery
And is recognised within24hrsImmediate repair.
If recognised later-repair
after 3-6 months

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Self Assessment & Review Gynaecology


URINE INCONTINENCE

According to International continence society, incontinence is defined as the complaints of any involuntary
leakage of urine which is a social and hygienic problem to the patient.
Classification

Urethral cause :

Extra urethral

Stress urine
incontinence

Urge incontinence

congenital

Mixed incontinence

e.g. etopic ureter

Acquired

overflow incontinence

urinary fistulas

Physiology of Micturition
Bladder Supply

Sympathetic

Parasympathetic
Via S2 S4
neurotrarsmitter
Acetyl choline

Via T11 L 2/ L3
Neuro transmitter
Nor epinephrine

Which acts on 2 types of receptors

acts via muscuranic receptors in


bladder

receptor located on urethra (close urethra


and Urine Storage and Continence)

receptor- located on bladder

1. Contracts detrusor muscle


2. Relaxes Urethra

(tone of bladder and promote storage of urine)

Promote bladder emptying

Stress Urinary Incontinence


Defined as involuntary escape of urine when intra abdominal pressure is increased as in
sneezing/coughing/laughing.
M/C type of urine incontinence in women.
SUI Can be due to

Bladder neck
Descent (Including urethral
hypermobility) (75-80%)

Intrinsic sphincter defect


(20-25%)

Risk Factors
i.

Vaginal delivery

iii. Obesity/Pregnancy

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ii.

Post menopausal atrophy

iv. Pelvic organ prolapse

Urinary Problems in Gynaecology & Traumatic Fistulas


Test for detecting stress incontinenceBonneys test : In this test the is patient asked to insert two fingers , in the paraurethral region and the bladder
neck is lifted up, and then the patient is asked to cough. If SUI gets corrected , then it is due to bladder neck
desent .If SUI persists, it is due to sphincter defect.
Marchetti test : is same as Bonneys test, except that instead of fingers, two Allis forceps are used.
Q tip test : A sterile cotton swab is introduced into the level of bladder neck. Then the patient is asked to
strain.Marked upward elevation of cotton tip (>30) indicates urethra hypermobility. Goniometer is used to measure
the urethero vesicle angle.
Cystometry Main objective is to rule out urge incontinence.
Normal Values:

Residual urine less than 50mL

First desire to void between 150 and 200mL

Capacity of strong desire to void more than 400mL

No detrusor contractions during filling despite provocation

No leakage on coughing or on any provocation

Voiding by voluntarily initiated and sustained detrusor contraction

Flow rate during voiding more than 15mL/sec with a detrusor pressure less than 15cm of water during filling
and less than 70cm of water during voiding

Abnormal cystometry
If there is leak of urine in the absence of a rise in detrusor pressure, stress incontinence is diagnosed. Urge
incontinence is diagnosed during the filling phase if there are spontaneous or provoked detrusor contractions
while the woman is trying to inhibit micturition. Thus stress incontinence is actually a diagnosis by exclusion.
Management:
1st line of mgt: Pelvic floor exercise called as kiegels exercises.
Definative management : Surgical management.
The choice of surgery is usually between a retropubic urethropexy and a sling operation. These are the currently
employed first line operations for stress incontinence. In general with concomitant prolapse a vaginal route is
preferred and sling surgery is done. If the woman is undergoing a laparotomy for any other reason urethropexy is
preferred. This can also be done laporoscopically.
Retropubic Urethropexy (Abdominal Procedure)
It involves attaching the fascia around the urethra and bladder neck to a supporting structure in the anterior
pelvis. This elevates the blader neck to an intra-abdominal position. The main problem is postoperative voiding
dysfuncion, detrusor overactivity and pelvic organ prolapse.
Two types of surgeries can be done in retropubic urethropexyA. The Burch colposuspension-most commonly done urethropexy wherby the fascia at the level of bladder
neck are attached to the iliopectineal ligament or Coopers ligament. The success rates are as high as 90%.
B. The Marshall-Marchetti-Krantz or MMK involves attachment of the periurethral facia to the back of the pubic
sympysis. A complication specific to this procedure is osteitis pubis and hence this procedure is no longer
used.
Sling operations
A sling is passed around the bladder neck and urethra and attached above to the anterior rectus facia so that a
supporting hammock is created for the urethra. The urethra is supported and also occluded when the intraabdominal pressure is increased, examples of this technique are-

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Tension free vaginal tape (TVT) and Trans Obturator Tape (TOT): Both TVT and TOT are currently being
widely used as primary operations for stress incontinence.
In TVT-a propylene mesh is placed at the midurethra through retropubic space whereas in TOT it is passed
through a midurethral vaginal incision medial to obturator foramen instead of through the retropubic space.
Note : The most common complication of TVT is bladder perforation(5%), most serious is bowel or vascular
injuries (both <1%).
Other procedures :
Kellys plication
This operation was the standard first line of treatment previously. The principle was supposed to be elevation of
bladder neck by placating the facia under the urethra. Cure rates are low, and so it is not recommended today.
Needle suspension procedures
Peryra, stamey and Raz procedures- these operations also have lower cure rates and are not currently performed.
Periurethral bulking agents
It is a simple technique, used in recurrent stress incontinence. A bulking agent like collagen is injected transurethrally.
Surgeries for SUI

Bladder neck descent +

Intrinsic sphincter defect

Urethral hypermobility

Vaginal

Abdominal urethropexy

1. Kellys

1. Bursch (M/C)

2. Needlesuspension surgery

2. MMK

a. Pereyra
b. Stamey
c. Raz

3. Artificial

1. Sling surgeries

2. Periurethral collagen

Urinary

e.g. TVT, TOT (M/C)

injection (through

sphincter

Urge Incontinence:
It is more common is older females.
Characterised by involuntary leakage of urine accompanied by urgency
It is can be mainly due to detrusor overactivity which can be
Idiopathic
Due to neurogenic causes like:
1. CVA
2. Alzheimers disease
3. Multiple sclerosis
4. Parkinsonism
5. Diabetes
It can also be due to causes like:
Cystitis/UTI
Bladder Stones/Cancer
Urethral obstruction

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cystoscopy)

Urinary Problems in Gynaecology & Traumatic Fistulas


Investigations
1. Urine culture (to rule out infection)
2. Cystourethroscopy (to rule out causes like bladder tumor/calculus)
3. Cystometry
Management:
Urge incontinence is best treated by behavioural therapy and anti cholinergic drugs. (To decrease detrusor
contractions).
Anti cholinergic used are:
1. Tolterodine
2. Hyoscyamine
3. Oxybutynin
4. Dicyclomine
So friends now with this background lets get on to the Qs on fistulas and incontinence.

EXPLANATION & REFERENCES


1.

Ans. is c i.e. Obstructed labour


Ref. Shaw 15/e pg -184; William Gynae. 1/e, p 573
In developing countries, 90% of genito urinary fistulas arise from obstetric trauma, specifically from
... William Gynae. 1/e, p 573
prolonged or obstructed labour.
Most common Genital Fistula is vesico vaginal fistula and so above statement holds good for VVF also.
The fistula resulting from pressure during long and difficult labour always involve the trigone of the bladderQ.
Whereas In developed countries, latrogenic injury during pelvic surgery is responsible for 90% of VVF.
In industralised countries, hysterectomy is the most common surgical cause of VVF, accounting for
approximately 75% of fistula cases. Laparoscopic hysterectomies were associated with the greatest
incidence followed be abdominal and vaginal.
... Williams Gynae. 1/e, p 573
Extra Edge :
Most common in fistulae
MC urinary fistula
MC cause of VVF in india
MC cause of Uretero Vaginal Fistula
MC cause of Vesico Uterine fistula
MC cause of Recto Vaginal fistula

2.

Ans. is d i.e. Uretero vaginal fistula

VesicovaginalQ
Obstructed labourQ
Injury to ureter after gynaecological operationQ
especially Wertheim hysterectomyQ
Cesarean sectionQ
Cesarean perineal tearQ

Ref. Jeffcoate 7/e, p 263, 265

Continuous dribbling of urine following hysterectomy points towards urinary fistulas as the diagnosis.
In case of urinary fistulas, if the patient never needs to void as there is continous dribbling it signifies that the
fistula communicates with the bladder. If, there is filling and emptying of bladder along with the fistula, it suggests
a fistula opening into one ureter i.e. Uretero vaginal fistula.Q
As far as urethral fistula are concerned, they give little trouble because the urethra is normally empty of urine.
However during micturition urine passes through the fistula and may then fill the vagina to dribble during body
movements for a short time afterwards.
This patient is developing symptoms on the seventh day can be explained by : Fistulas resulting from
accidental, surgical and obstetrical trauma are produced in two ways. They can be caused by direct injury
such as cuts and then they manifest themselves immediately by hematuria and incontinence. Alternatively
if they are the outcome of pressure necrosis or of ischemia, in such a case urinary incontinence, fever and
burning micturition develops 7-14 days after the accident.
...Jeffcoate 7/e, p 263

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Before concluding lets rule out other options as well :
In stress incontinence, dribbling of urine occurs only when intrabdominal pressure is raised.
In urge continence the patient has urge to void urine at a moments notice and she is unable to control her
bladder and passes urine instantly.
3.

Ans. is c i.e. Foleys Catheterisation

Ref. Shaw 15/e pg -185; Dutta Gynae 5/e, p 404

Urine culture is mandatory before surgery and infection should be treated. The urine is collected by
Catheterisation.
... Shaw 14/e, p 167
In VVF
Preoperative collection is best to be done through ureteric catheterisation.

... Dutta 5/e, p 404

So friends undoubtedly Ureteric catheterisation. (Dont get confused it is not Foleys catheterisation) is the
best method for collecting urine for culture in a case of VVF. This option is not given, so, we will have to look for
next best option.

Urine collected through a sterile vaginal speculum will not serve the purpose because of contamination.

Midstream clean catch sample is also contaminated in vesicovaginal fistulas. (Option b)

Supra pubic aspiration done after proper cleansing and draping the patient with full bladder, is easy and next
best method of urine collection after ureteric catheterization. But the only prerequisite for this method of collection
is A full bladder which cannot be fulfilled in a case of VVF as urine continuously dribbles from the vagina and
therefore bladder is never full. (Ruling out Option a)

... Dutta Gynae 5/e, p 405 (Option d)

By exclusion our answer is Foleys catheterization, although chances of contamination are present in Foleys
catheterization but they can be reduced if proper vaginal douching is done prior to collection of urine.
4.

Ans. is b i.e. Cystoscopy

5.

Ans. is c i.e. Cystoscopy


Ref. Principles & Practice of Obs & Gynae Vol. II for P-Gs 3/e by Pankaj Desai, Narendra Malhotra p 613, Telinde
9/e,p1104
According to Dutta Gynae and Shaws
Most useful test for fistula is the 3 swab test and cystoscopy is not routinely done.
But according to higher textbooks (Like Principles & Practice of Obs & Gynae for P.G 3/e by Pankaj Desai)
Evaluation of any fistula includes 3 steps
A. Clinical Examination which includes:
a. Pelvic Examination
b. The three swab vaginal test It helps in diagnosing fistula and differentiating between the other varieties of
fistula
B. Imaging study It serves three functions.
a. To ascertain that there is no ureteric involvement either during initial injury or due to subsequent fibrosis
b. To examine the surrounding tissue planes for abscess formation or unresolved urinoma.
c. To search for residual malignancy in a post radiation fistula
A spiral CT with 3D reconstruction is now the standard of care.
C. Cystoscopy
Cystoscopy is indispensable.
... Principles & practice of obs & gynae for PGS 3/e, p-613- Pankaj Desai Narendra Malhotra

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Urinary Problems in Gynaecology & Traumatic Fistulas


Cystocopy is useful for knowing the:

Number and size of VVF, with their exact localion in relation to the ureters and bladder neck.

The state of the margins of the fistulas If needed a biopsy can be taken from the margin of a post radiation
fistula.

6.

Ans. is c i.e. 3 months

7.

Ans. is a i.e. VVF

Ref. Shaw 15/e pg -186, 187; Dutta Gynae. 5/e, p 405

Management of VVF is : Surgical management :


Timing of surgery
(a) Small urinary fistulas sometimes heal spontaneously during the first few weeks.
(b) However in a case of established fistula it is better to wait for about 3 monthsQ for all tissue inflammation to
subside. If one attempt fails to heal fistula, second attempt is done after 3 months.Q
C) In fistulas following surgery waiting period is 3-6 months.
(d) In fistulas following radiation : 6 months to 2 years time can be taken before inflammation subsides.
Techniques of Repair

Layer technique

Latzko procedure(for fistulas following hysterectomy)

Chassar Moir technique.Q

Postop Management

Continuous bladder drainage for 14 daysQ.

Antibiotic coverage.

No vaginal examination, P/S, intercourse x 3 months.

Avoid pregnancy for 2 years.

In pregnancy after repair of vaginal fistula elective cesarean is done.Q

Extra Edge :
This question is an old one so here answer will be 3 months but if this question is repeated now remember the
following lines from Williams Gynae. 1/e, 575 - 576 :
Timing of repair : Traditional teaching recommends delayed repair of fistulas at 3 to 6 months afte injury.
However, this old dictum is probably no longer applicable. Most agree that unless there is severe infection or
acute signs of inflammation, waiting is not necessary . Early surgical intervention of uncomplicated fistulas does
not affect closure rates, yet appears to reduce social and psychological patient distress (Balivas, 1995). Fistulas
identified within the first 24 to 48 hours postoperatively can be safely repaired immediately with success rates of
90 to 100 percent.
8.

Ans. is b i.e. Uretero vaginal fistula

Ref. Dutta Gynae. 5/e, p 403, Shaw 15/e pg -186

The three swab test helps to confirm the Vesico Vaginal Fistula and to differentiate between vesico vaginal
fistula, uretero vaginal and urethrovaginal fistula.
Procedure of Three swab test A catheter is introduced into the bladder through the urethra.
Three cotton swabs are placed in the vagina as follows :

One at vault,

One at the middle

One just above the introitus.

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Self Assessment & Review Gynaecology


Methylene blue dye is instilled into the bladder through a rubber catheter and swabs are removed for
inspection.
Observation

Interpretation

1.

Upper most swab soaked with urine but unstained with dye

Uretero vaginal fistulaQ

2.

Upper and lower swab remain dry but the middle swab soaked with dye

Vesico vaginal fistulaQ

3.

The upper two swab remain dry but lower one soaked with dye

Urethro vaginal fistulaQ

9.

Ans. is d i.e. Below cardinal ligament where uterine artery crosses

10.

Ans. is b i.e. Peristaltic

movement

Ref. Studd progress in Obs and GynaeVol 16 p 306

The crossing of the uterine vessels and ureter is at the level of internal os. Over here the ureter runs below the uterine
vessels (water below the bridge)and the distance between the ureter and uterine vessels is only 1.5 2 cm.
The ureter can get injured at all the sites mentioned in the question but during gynaecological surgeries the commonest
site of injury to ureter is where it crosses below the uterine arteries.
The next common site of injury is behind the infundibulopelvic ligament at the pelvic brim.
At operation ureter is recognized by :
1. Its pale glistening appearance
2. By a fine longitudinal plexus of vessels on its surface
3. More particularly by its peristaltic movement
4. By palpation between finger and thumb as a firm cord which, when escapes, gives a characteristic snap.
Absence of pulsation does not serve to identify a structure as ureter because veins and obliterated umblical artery
are also non pulsatile.
11.

Ans. is b i.e. 40% heal spontaneously


Ref. Dutta Gynae 5/e, p 409-410; Telindes; Operative Gynaecology 9/e, p 1088 - 1089; Dew Hursts 7/e, p 543;
Shaw 15/e pg -187

Uretero vaginal fistula most commonly follows trauma during pelvic surgeries like Total Abdominal Hysterectomy,
Wertheims hysterectomy and Vaginal hysterectomy.

Symptoms :
Escape of urine through the vagina (True incontinence)Q
Besides incontinence patient has also got the urge to pass urine and can pass urine normally.Q
Patient may complain of :
Flank pain
Temperature
Retroperitoneal fluid collection (caused by urinary leak into the abdominal cavity due to transection of the
ureter i.e. option a is correct).
Investigation :
1. Three swab test differentiates it from VVF.
2. I.V. Indigocarmine test : if the urine in the vagina is unstained following three swab test, indigocarmine is
injected intravenously, if urine becomes blue diagnosis of uretero vaginal fistula is confirmed.
3. IVP : In case of ureteric transactions partial or complete, pyelography fails to show part or whole of the ureter
on the transected side and there may be pooling of dye in the peritoneal cavity.
4. USG : Following ureter ligation, USG may reveal hydronephrosis and dilated ureter proximal to the site of
block.
5. CT scan.

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Urinary Problems in Gynaecology & Traumatic Fistulas


Management :
Time of Repair

Ureteric injury/ureteric fistulas must be repaired as soon as the diagnosis is confirmed.

The best chance of healing with primary repair is when reoperation is done within the first 48 hours. Our
opinion is that some form of immediate intervention must be undertaken no matter what the type of injury
has occurred.
... Telinde Operative Gynecology 9/e, p 1088
Uretero vaginal fistula should be repaired as early as possible to prevent upper urinary tract damage
... Dewhurst Obs. & Gynae. 7/e, p 543
Technique of Repair
a. When ureteral sheath is denuded for a short segment, it is best to do nothing.
b. When ureter is kinked due to a suture, it should be removed or deligated immediately.
c. If clamped tissue is healthy and viable, splinting/stenting is done for 7-10 days for further.
Ureteric transection :
a. Ureteroneocystostomy (implantation of ureter into the bladder) when injury is near bladder.
b. Uretero ureterostomy : end to end anastomosis : done when ureter is dissected above mid pelvis.
c. Bladder flap operationQ (MODIFIED BOARISQ) : done when ureter is short or injury is at the level of pelvic brim.
d. Segment of small intestine may be used for repair.
Ref. Shaw 15/e pg -188; Jeffcoate 7/e, p 266

12.

Ans. is c i.e. Vesico uterine

13.

Ans. is b and c i.e. UVF (Uterovesical fistula) and Bladder endometriosis

Ref. Shaw 15/e pg -188

The condition of cyclical passage of menstrual blood in urine is called as Menouria. ... Jeffcoate 7/e, p 266
Menouria :

14.

It is seen in uterovesical fistulaeQ

Usually follows caesarean sectionQ

The patient complains of hematuria/passage of menstrual discharge via urethra at the time of menstruation.
Patient does not have Urinary incontinence.Q

Mensouria is seen when Utero vesical fistula opens into the uterus above the isthmus.Q

The presence of the fistula can be demonstrated by hysterography (but not by cystography) and cystoscopy.Q

Treatment is by abdominal repair.Q

Another Important cause of cyclical hematuria is endometriosisQ of bladder.

Ans. is a i.e. Colostomy


Ref. Novak 14/e, p 704; 15/e p 711, Sabiston T.B. of Surgery 17/e, p 1500; Washington Manual of Surgery 3/e, p 279
Rectovaginal fistula is a communication between the epithelium linedQ surfaces of the rectum & the vagina.
Diagnosis :
History of passing flatus, stool, mucus or blood per vagina.
Diagnosis is made usually with :

Speculum examination (P/S)

Anoscopy / Proctoscopy

Methylene blue enema

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Endoanal ultrasound can determine the severity of trauma.

Classification :
Congenital

Acquired

due to congenital abnormalities

Trauma
Inflammatory bowel disease
Irradiation
Neoplasia
Infection
Other causes

Now lets talk about Rectovaginal fistula that results due to obstetric injury :
Initial Treatment : A small rectovaginal fistula may be managed with conservative medical approach, in hope that
decreasing the fecal stream will allow closure of fistula. Large rectovaginal fistula for which there is no hope of
spontaneous closure, are best managed by performing initial diverting colostomy.Q
Ref. Novak 14/e, p 704; 15/e p 711
Definitive Treatment : However the initial management is either medical conservative approach (small fistula) or
a diverting colostomy (large fistula) to allow for the pelvic inflammation to subside, but the definitive treatment is
surgical repair.
If even after several months (3-6 months) of conservative approach Fistula does not heal, surgical repair is done.
15.

Ans. is d i.e. Injury to hypogastric plexii

Ref. Jeffcoate 7/e, p 857

Retention of urine in females can be explained by one of the four mechanisms.


Failure of Detrusor
muscle to contract

Interference with
the opening of
internal sphincter

Spasm of external
urethral sphincter

Obstruction
of Urethra

Due to

Due to

Due to

Inhibition of detrusor
muscle due to emotional

upsets like hysteria, fear

Nervousness

Congenital atresia

uterus, cervical

Perineal injuries

Foreign body /

Paralysis of excitatory

leiomyoma, impacted

nerves to bladder due to

ovarian cyst,

disease of CNS

hematocolpos, hemat-

Operations on

ocoel crowding the


the pelvic space,

Urethritis

complicated ectopic

Neurological disease

radical hysterectomy)

Tight packing of vagina

Buttressing of tissue

Calculi (Rare)

perineum & perianal

Paralysis of excitatory

pelvic surgery (like

tissues

Stenosis following
injury or infection

Paraurethral cysts or
abscess

Ca vulva, vagina &


urethra

Angulation of urethra

Bladder muscles become

behind the urethro-

in gross prolapse

atonic from over stretching

vesical junction after

cases.

surgery for stress incontinence

Ca cervix & Ca vagina

Over enthusiastic
urethrocystopexy

114

during child birth

nerves to bladder due to


injury during extensive

Retroverted gravid

Urinary Problems in Gynaecology & Traumatic Fistulas


16.

Ans. is a i.e. Pelvic Floor muscle Exercises


Ref. Dutta Gynae 5/e, p 586; Novak 14/e, p 875; Williams Gynae 1/e, p 525-526, Textbook of gynae, sheila
balakrishnan 1/e, p328
The most recommended non surgical treatment for stress incontinence is Pelvic floor muscle exercise.
Pelvic floor muscle training should be offered as first line conservative management for stress
incontinance.
... Novaks 14/e, p 875; Dewhurst 10/e, p 486
Pelvic floor exercises are the mainstay of conservative therapy for stress incontinance.
... Urinary incontinence in primary care (2000)/73
Conservative management options for Stress Incontinance
Pelvic floor muscle training exercises/Kiegels exercises (Mainstay/First line of management)
Vaginal cones/Weights (also help strengthening the muscles)
Electrical stimulation (alternative to pelvic exercises)
Bladder training/Scheduled voiding (most useful for urge incontinence)
Biofeedback
Pharmacotherapy
Duloxetine (First drug specifically developed and licensed for this indication. It is a selective serotonin and
norepinephrine reuptake inhibitor.)
Tricyclic antidepressants
adrenergics (eg ephedrine)-to increase the tone of urethra.Main problem with these drugs is that they
can lead to hypertension.
Estrogens (to be given in postmenopausal women who are atrophic)
Also know
Avoiding Caffiene and carbonated drinks helps to control urine frequency and urgency.

17.

Ans. is 17 is a i.e. Stress incontinence


Ref: Shaw 14/e. p 174, Textbook of Gynae shiela Balakrishnan 1/e.p 330
As discussed in preceeding text, kellys plication/Kelleys stitch was the standard first line of treatment for SUI
previously but due to low cure rates, it is not being done these days. 5 year failure rate for kellys plication is
approximately 50%

18.

Ans. is a i:e Stress urinary incontinence

Ref. Telinde 9/e, p 1035-1037

Bonneys test is performed in the clinical evaluation of SUI. In the Bonneys test, two fingers are placed in the
vagina at the UV junction on either side of the urethra and the bladder neck is elevated.
On straining or coughing, leakage of urine indicates of positive test. A positive test indicates that the SUI is due to
bladder neck descent and urethral hypermobility and can be corrected by bladder neck suspension surgeries.
A negative test i.e. leakage of urine-means SUI is due to intrinsic urethral sphincteric deficiency and results of
performing bladder neck suspension surgery will not be good.
Note : Marchetti test is same as Bonneys test, but two Allis forceps are used instead of fingers.
19.

Version I
Ans. is d i.e. Tension Free Vaginal Taping (TVT):
Evidence Based Urology (Wiley Blackwell) 2010/193 Pelvic Floor Dysfunction. A multidisciplinary Approach
(Springer) 2006/117: Hernia Repair Sequalce (Springer) 2010/440; Assessing and Managing A cutely III Adult
Surgery Patient (John Wiley and Sons) 2007/182

115

Self Assessment & Review Gynaecology


19.

Version II
Ans. is a i:e Bursch colpo suspension

Ref. Telinde 9/e, p 1052-1056

As discussed in preceding text SUI is managed basically by performing either of the two surgeries viz1. Burch colposuspension
2. Tension free vaginal tapes/tension free obturator tapes.
The rates of success of these two surgeries are comparable, so if either of them is given in options, we will chose
it.
So in version II- Answer is Burch colposuspension
Procedure

Telinde, 9/e, p 1050-6.


Long-Term Success Rate (%)

Burchs colposuspension

89.5

Stameys repair

85

Kellys repair

50-60

Aldridge Repair

85

Now suppose both Burch colposuspension and TVT is given (Like in version I), then rememberTension Free Vaginal Tape (TVT) has emerged as the treatment of choice for genuine stress incontinence in
recent years
Tension Free Vaginal Tape (TVT) is a simple procedure that may be performed under local anesthesia, has a
decreased operative and recovery time, and is as effective as Burch colposuspension which was earlier considered
the procedure of choice.
A number of surgical procedures have been developed to treat genuine stress incontinence and most aim to
elevate and support the bladder neck. Burch colposuspension was the procedure of choice, but in recent years
this has been superseded by the Tension free Vaginal Tape which is showing comparable results and is less
invasive
Ref. Assessing and managing Acutely III Adult Surgery Patient (John Wiley and sonsd) 2007/440
Tension Free Vaginal Tape (TVT)

20.

Tension Free Vagina Tape (TVT) is a type of suburethral sling that does not have typical suspension sling like
mechanism of action.

TVT involves placement of synthetic polypropylene mesh/tape under the urethra. The sling is placed at the
level of mid-urethra (midurethral sling)

TVT is a simple procedure that can be performed under local anesthesia, and has the advantage of decreased
operative time and decreased recovery time, while providing a good outcome.

TVT is believed to be as effective as Burchs colposuspenstion with cure rates approaching > 80%.

Ans. is a, c , d and e i.e. anterior colporrhaphy, colposuspension, pelvic floor excercises and sling operation.
Ref. Shaw 14/e, p 174, Dutta gynae 5/e p387 389, Textbook of gynae, shielaBalakrishnan 1/e, p 329 - 330
As explained in preceeding text:
Pelvic floor exercises
Sling operation
Colposuspension (Burch) are all done for management of SUI.
As far as anterior colporhaphy is concerned - kellys plication is anterior colporhaphy + Bladder neck repair, so I
have included it in correct option also.

21.

Ans. is d i.e. Osteitis pubis


Ref. Telinde 9/e, p 1057-1058, Textbook of Gynae, Sheila Balakrishnan 1/e, p 329.

116

Urinary Problems in Gynaecology & Traumatic Fistulas


Marshall Marchetti-Krantz (MMK) procedure, involves the attachment of the periurethral tissue to the symphysis
pubuis. In approximately 3% of patients undergoing the procedure, osteitis pubis develops.
22.

Ans. is a, b, and d i.e. Cervical fibroid; Retroverted Gravid uterus; and Severe UTI
Ref. Jeffcoate 7/e, p 855
Important gynaecological causes of acute retention :
Acute retention

Other symptoms

Diagnosis

Retention +

Primary amenorrhea

Hematocolposcopy

Retention +

Secondary amenorrhea

Retroverted gravid uterus

Retention +

Menorrhagia

Uterine leiomyoma (cervical fibroid)

Retention +

No menstrual upset

Ovarian or broad ligament tumor

Retention +

Irregular bleeding

Threatened abortion from a retroverted gravid


uterus or pelvic haematocoele or pelvic abscess

Besides the above causes Jeffcoate 6/e, p 855-858 gives an exhaustive list of other causes of urinary retention- in
which urethritis causing spasm of voluntary external urethral sphincter and acute urinary retention is given.
23.

Ans. is c i.e. Impacted cervical fibroid

Ref. Read below

The patient in the question :


Was being treated for infertility.
Now H/O a 6 weeks of amenorrhea.
Presents with urinary retention.
The first diagnosis which comes in our mind is Retroverted gravid uterus.
Points which favour the diagnosis are : The woman is pregnant and has complain of urinary retention.
But friends, here it is important to understand that retroverted gravid uterus causes urinary retention at 14 - 15
... Jeffcoate 7/e, p 299
weeks of gestation (not 6 weeks).
So Option a. is ruled out
Option b Pelvic hematocele
Pelvic hematocele is formed in a patient complaining of 6 weeks amenorrhea in case of ectopic pregnancy.
... Jeffcoate 6/e, p 212
Though pelvic hematocele causes urine retention but then other symptoms (pain) and signs of ectopic pregnancy
should be present.
Option c Impacted cervical fibroid
A cervical fibroid impacted in pouch of Douglas can cause retention of urine. The onset of retention is
acute and usually occurs immediately before menstruation, when the uterus is further enlarged by
congestion or during early pregnancy.
... Jeffcoate 7/e, p 493

24.

Fibroid is associated with infertility.


Thus an impacted cervical fibroid can explain all features seen this woman and is our option of choice.
Ans. is b, c, d and e i.e. Associated with endometriosis; It is a cause of infertility; Causes menorrhagia;
Ref. Shaw 15/e pg -345-347; Jeffcoate 7/e, p 295-297
and Associated with PID
The usual position of the uterus is one of anteversion and anteflexion, in which the body of the uterus is bent
forward at its junction with cervix.
Retroversion is a condition in which axis of cervix is directed upward and backward (instead of forward).

117

Self Assessment & Review Gynaecology


Causes
Developmental

Seen in 20% of patients


Retroversion can never be
congenital (it is always developmental)
malformation as the uterus is without
version and flexion at birth.
..... Jeffcoate 7/e, p 295

Acquired

Mobile retroversion
Prolapse
Puerperium

Fibroid

Ovarian cyst
(pushes uterus backward)

Fixed retroversion
PID
Pelvic tumors
Chocolate cyst of ovary
Pelvic endometriosis

Symptoms :
Mobile retroversion is usually symptomless, main disadvantage being increased risk of perforation of the uterus
at the time of instrumentation.
Symptoms which can be seen are :
Spasmodic dysmenorrheaQ
Pelvic congestion syndrome causing :
Congestive dysmenorrhea
Polymenorrhagia
Premenstrual low backache
Dyspareunia (it is the most specific and genuine complain in case of retroversion)
Leucorrhoea
Infertility : as cervix is directed forward away from the seminal pool and the ejaculation of semen directly into the
external os.
Abortion : can cause abortion between 10th to 14th week.
Treatment :
If retroversion is mobile no treatment is required.
In patient complaining of dyspareunia backache with retroverted uterus : Hodge pessary may be used to keep
uterus in anteverted position.
Surgical management : Modified Gilliams operation
Plication of round ligamentQ
Baldy webster operationQ
25.

Ans. is c i.e. In a setting of antibiotic treatment

Ref. Ananthnarayan 7/e, p 275 - 276

The concept of significant bacteriuria is given by Kass.


Significant bacteriuria refers to bacterial count more than 105/ml of urine
Prerequisite for collection of urine for culture.
Clean voided mid stream samples of urine are employed for culture. Normal urine is sterile but during voiding
may become contaminated with genital commensals.
Even under ideal conditions (urine collected by catheterisation), rate of urinary infection is 2%.
In men, it is sufficient, if mid stream urine is collected after the prepuce is retracted and the glans penis
cleaned with wet cotton.
In women, anogenital toilet is more important and should consist of careful cleaning with soap and water.
Results :
When bacterial count are more than 105/ml of urine, it is called Significant bacteriuria.
Counts of 104/ml of urine are due to contamination during voiding and are of no significance.
In a patient on antibiotic treatment with some bacteria like staph. aureus, even low counts i.e. < 105/ml may be
significant.

118

Urinary Problems in Gynaecology & Traumatic Fistulas

REVIEW QUESTIONS
DE
1.

2.

3.

4.

5.

Which of the following is the site of bladder injury


(UP 01)
in abdominal hysterectomy is :
a. Anterior wall
b. Posterior wall
c. Medial wall
d. Lateral wall
Note : Posterior wall of bladder is in relation to the
anterior wall of vagina, therefore it is most likely to
be damaged
Commonest cause of genital fistulae in India :
(UP 05)
a. Obstructed labour
b. Operation therapy
c. Radiotherapy
d. Laparoscopic injuries
[Ref. Shaw 15/e pg -183; Williams Gynae. 1/e,
p 573]
Vesicovaginal fistula repair surgery, the bladder
(UP 06)
drainage should be done for :
a. 6 days
b. 10 days
c. 12 days
d. 14 days
[Ref. Shaw 15/e pg 187]
A 70 year old female patient presents with
recurrent dysuria, with urine routine microscopy
normal and urine culture negative. Treatment that
(Delhi 99)
should be given is :
a. Local antifungal cream
b. Antibacterial chemotherapy
c. Hormone replacement therapy
d. None of the above
[Ref. Shaw 15/e pg -64]
Most common type of urinary fistula is :
a. Uterovaginal
(Delhi 01)
b. Vesicovaginal
c. Urethrovaginal
d. None of the above
[Ref. Shaw 15/e pg -184]

Answer

1. b. Posterior ...
6. d. Methylene ...

2. a. Obstructed ...
7. b. Three ...

6.

7.

Clinically vesicovaginal and ureterovaginal fistula


are differentiated by :
(Delhi 04)
a. USG
b. IVP
c. Cystoscopy with dye
d. Methylene blue three swab test
[Ref. Shaw 15/e pg -186]
Following procedure is used to differentiate
between vesicovaginal and ureterovaginal fistula:
(Karnataka 2008)
a. IVP
b. Three swab methylene test
c. Micturating cystourethrography
d. Idigocarmine test
[Ref Smith urology 17/e, p 583, Shaw 15/e pg -186]

8.

9.

10.

Commonest cause of VVF in India is :


a. Obstetric causes
(DNB 06, 00)
b. Carcinoma cervix
c. Gynae. operations
d. Bladder stone
[Ref. Shaw 15/e pg -184]
Vesicovaginal fistula by obstructed labour
(DNB 00)
manifests .......... of delivery :
a. Within 24 hours
b. Within 72 hours
c. Within 1st week
d. After 1st week
[Ref. Jeffcoate 7/e, p 264]
Bonneys test is used to demonstrate :
(DNB 99, 91)
a. Stress incontinence
b. Urge incontinence
c. Fibroids
d. True incontinence
[Ref. Shaw 15/e pg -191]

3. d. 14 days
8. a. Obstetric ...

4. c. Hormone ...
9. d. After ...

5. b. Vesicovaginal
10. a. Stress ...

119

Self Assessment & Review Gynaecology


11.

12.

13.

14.

15.

16.

Stress incontinence is best corrected by :


a. Colpo-suspension
(AI 94)
b. Hysterectomy
c. Bladder neck repair
d. Bladder exercise
[Ref. Dutta Gynae 5/e, p 387]
Note : It is the basis of treatment in kelleys repair.
Important post operative management of a case
of VVF is :
(AIIMS 84)
a. Continuous bladder drainage
b. Antibiotics
c. Complete bed rest
d. Early ambulation
[Ref. Shaw 15/e pg -187]
Stress incontinence is repaired by ..... repair :
(DNB 95, PGI 88; UPSC 85 )
a. Manchester
b. Fothergills
c. Marshall Marchatti Krantz
d. Bonneys
[Ref. Dutta Gynae. 5/e, p 387; Shaw 15/e pg -193]
The causes of retention of urine in obstetrics and
gynaecology is / are :
(PGI 85)
a. Impacted ovarian tumour
b. Retroversion
c. Hemotocolps
d. Cervical fibroid
e. All
[Ref. Shaw 15/e pg -175-176]
Manifestation of uretero vaginal fistula is :
a. Overflow incontinence
(PGI 96)
b. Hydronephrosis
c. Continuous incontinence
d. Stress incontinence
[Ref. Shaw 15/e pg -185]
Note : Patient will have continuous incontinence
+ urge to void normally. This is because the
opposite ureter is intact.
Commonest cause of rectovaginal fistula in India
is :
(PGI 88)
a. Carcinoma cervix
b. Carcinoma vagina
c. Crohns disease
d. Internal malignancy
[Ref. Shaw 13/e, p 162 - 163]

Answer

120

11. a. Colpo-sus....
16. None
21. c. Improper ...

12. a. Continuous ...


17. a. Prolapse ...

17.

18.

19.

Note : Majority of rectovaginal fistulas result from


obstretic injuries, usually a complete tear of perineum
which has been imperfectly repaired.
Stress incontinence is a common symptom in :
a. Prolapse uterus
(Kerala 95)
b. Fibroid
c. Adenomyosis
d. VVF
[Ref. Shaw 15/e pg -336, Dutta Gyane 5/e p 382]
Marshall-Marchetti-Krantz surgery is done for :
(Karn. 96)
a. Stress incontinence
b. Urge incontinence
c. Vesico vaginal fistula
d. Bladder obstruction
[Ref. Dutta Gynae 5/e, p 387; Shaw 15/e pg -193]
Which causes stress incontinence?:

(RJ 2009)

a. VVF
b. RVF
c. Ureterovatinal fistula
d. Procidentia
[Ref. Shaw 15/e pg -336]
20.

Incontinence in elderly female is most commonly


due to :
(CUPGEE 99)
a. Detrusor instability
b. True stress incontinence
c. Vesicovaginal fistule
d. Outlet obstruction
[Ref. Dutta Gynae 5/e, p 389;Shaw 15/e pg -195]
Note : Urge incontinence due to deterusor
instabality (DI) is the second most common cause of
urinary incontinence in an adult female. The first
being GSI (Geniune stress incontinence) However,
in the elderly group, DI is the commonest.
... Dutta Gynae 5/e, p 389

21.

Commonest cause of recto vaginal fistula is :


a. Following Wertheims operation
(TN 90)
b. Pressure necrosis during labour
c. Improper repair of perineal tear
d. Abnormal presentation
[Ref. Shaw 13/e, p 162 - 163]

13. c. Marshall ...


18. a. Stress ...

14. e. All
19. d. Procidentia

15. c. Continuous ...


20. a. Detrusor ...

Urinary Problems in Gynaecology & Traumatic Fistulas


22.

23.

24.

25.

26.

27.

One week after an extended hysterectomy, the


patient leaks urine per vaginum. In spite of the
leakage, she has to pass urine from time to time.
The most likely cause is :
(UPSC 97)
a. Vesico-vaginal fistula
b. Ureterovaginal fistula
c. Stress incontinence
d. Overflow incontinence
[Ref. Jeffcoate 7/e, p 265]
A primipara who had a prolonged labour and
difficult vaginal delivery three months ago
presents with complains of incontinence of loose
stools and flatus from the day of delivery. The
most likely diagnosis :
(UPSC 99)
a. Chronic diarrhoea
b. Recto-vaginal fistula
c. Haemorrhoids
d. Complete perineal tear
[Ref. Shaw 15/e pg -166-167]
Boaris Operation is :
(AP 97)
a. Renal pelvic flap
b. Urinary diversion
c. Bladder flap
d. Uretero- rectal anastanosis
[Ref. Bailey & Love 24/e, p 1313]
Chassar Moir technique is used in :
(AMU 05)
a. Vesico vaginal fistula
b. Stress incontinence
c. Urethrocoele
d. Enterocoele repair
[Ref. Shaw 15/e pg -187]
Kellys suture is done in :
(Calcutta 00;
a. Stress incontinence
CUPGEE 06)
b. Cervical incontinence
c. Genito-urinary prolapse
d. Vaginoplasty
[Ref. Shaw 15/e pg -193]
Commonest site of injury of the ureter in
hysterectomy :
(UPSC 85; PGI 88)
a. Where it enters the bladder
b. Crossing by uterine artery
c. Where it enters the pelvis
d. None of the above
[Ref. Telinde Operative Gynae 9/e, p 1084]

Answer

22. b. Ureterovaginal ... 23. d. Complete ...


27. c. Where it ...
28. d. After 1st week

28.

Vesicovaginal fistula by obstetric labour manifests


at after .............. delivery:
(DNB 2008)
a. Within 24 hours
b. Within 72 hours
c. Within 1st week
d. After 1st week
(Ref: Jeffcoates, 7/e, 263)
Note: If the fistulas are a result of direct injury e.g.cuts, then they manifest immediately. If they are a
result of pressure necrosis they manifest after 7-14
days. In case of obstructed labourmechanism of
injury is pressure necrosis hence it will manifest after
1st week.

29.

Which is not seen in ureteric fistulas: (AP 2008)


a. Pyelonephritis
b. Amenorrhea
c. Repair is done by fascial split
d. Hydronephrosis
[Ref Shaw 15/e pg -185]
Note : If the fistula develops as a result of ligation of
one or both ureters patient may develop
hydronephrosis and pyelonephritis.

30.

Dye test for fistula all true except: (Kolkata 2009)


a. If the middle swab is stained with dye, the
diagnosis is vesicovaginal fistula
b. If the lower swab is stained with dye the diagnosis
is urethrovaginal fistula
c. Upper most swab stained with urine but not with
dye and lower two swabs are dry, diagnosis is
ureterovaginal fistula.
d. If the middle swab is stained with dye, the
diagnosis is genuine stress incontinence.
[Ref. Shaw 15/e pg -186]
Note : In case of stress urine incontinence also, the
lower swab well get the stain with dye ... Smith urology
17/e, p 583.

24. c. Bladder ...


29. b. Amenorrhea

25. a. Vesico ...


30. d. If the middle ...

26. a. Stress ...

121