Vesico-vaginal fistula

Definition
There is communication between the bladder and the vagina and the urine escapes into the
vagina causing true incontinence. This is common type of genitourinary fistula.
Types
Fistula may be classified as—(i) Simple (Healthy tissues with good access) or (ii) Complicated
(tissue loss, scarring, difficult access, associated with RVF).
Depending upon the site of the fistula, it may be:
 Juxtacervical (close to the cervix)— The communication is between the
supratrigonal region of the bladder and the vagina (vault fistula).
 Midvaginal— The communication is between the base (trigone) of the bladder
and vagina.
 Juxtaurethral—The communication is between the neck of the bladder and
vagina (may involve the upper urethra as well)
 Subsymphysial—Circumferential loss of tissue in the region of bladder neck and
urethra. The fistula margin is fixed to the bone.

Etiology
1. OBSTETRICAL CAUSES
In the developing countries- commonest cause accounts for 80-90% of cases (developed
5-15%)
A. ISCHEMIC NECROTIC OBSTETRIC FISTULA
 Prolonged Obstructed labor
• CPD and malpresentation → trigone of bladder is nipped between
presenting part and pubic symphysis → ischemic tissue necrosis →
sloughing genitourinary fistula
• Slough take some days to separate → thus incontinence develops
7-10 days after delivery
B. TRAUMATIC FISTULA
 Instrumental Vaginal delivery such as destructive - operations or forceps
specially with kielland.
• Injury inflicted by bony spicule of the fetal skull in craniotomy
operation
C. In Caesarean section
• At risk in patient with previous LSCS
• If bladder is caught in the suture can cause ischemia leading to
fistula formation
• Rupture of scar of previous LSCS can implicate adherent bladder
base
 • In such direct traumatic injury, fistula and incontinence follows
soon after delivery
2. GYNAECOLOGICAL CAUSES
 OPERATIVE INJURY
 In developed countries it accounts for 70% of fistulas
 In nearly all gynecological operations one or other part of the urinary tract
is in danger
 URETER- is at risk in total hysterectomy especially radical hysterectomy,
removal of broad ligament tumors
 Risk of ureteral injury was seven times greater with laparoscopic
procedures than with open procedures
 URETHRA- is threatened during anterior colporrhaphy and sling
operation
3. MALIGNANCY
 Advanced carcinoma of cervix, vagina or bladder → may produce fistula by
direct spread
4. RADIOTHERAPY
 Excessive, misapplied and even well applied irradiation for pelvic malignancy esp
carcinoma of cervix causes endarteritis obliterans ischaemic necrosis fistula
 Late complication- takes 1-2 years to produce such fistula
5. INFECTIVE
 Vaginal foreign bodies, forgotten and retained pessariesChronic granulomatous
lesions such as genital tuberculosis, actinomycosis - rare causes of fistula

Pathophysiology
Prolonged labor/ Obstructed labor

Compression on bladder base between head & symphysis pubis

Ischemic necrosis

Sloughing

Fistula formation
Clinical Features
 SYMPTOMS
 Continue escape of urine per vagina (true incontinence).
 Patient has got no urge to pass urine.
 SIGNS
 Vulvar Inspection
 Escape of ammonia smelling discharge per vagina
 Evidence of sudden and excoriation of the vulvar skin.
 Varying degree of perineal tear.
 Internal Examination
 If fistula is big enough, its position, size and tissue at the margins are to be noted.
 There may be varying degree of vaginal atresia.
 Speculum Examination
 A sim’s speculum in sim’s position gives a good view of the anterior vaginal wall.
When the vagina becomes ballooned up by air because of negative suction.
 The size, site and number of fistula.
 Often, the bladder mucosa may be visibly prolapsed through a big fistula.
 A tiny fistula is evidenced by a puckered area of vaginal mucosa.

Diagnostic Investigation
 History taking
 Pelvic Examination
 Dye test
- When the methylene blue solution is introduced into the bladder by a catheter, the dye
will be seen coming out through the opening.
- A metal catheter passed through the external urethral meatus into the bladder when
comes out through the fistula not only confirms the VVF but ensures patency of the
urethra.
 Retrograde pyelography: for the diagnosis of exact site of ureterovaginal fistula.
 Intravenous urography: for the diagnosis of ureterovaginal fistula.
 Cystography: not done in cases with VVF. It may be done in a complex fistula or
vesicouterine fistula where uterine cavity (lateral view) may be seen.
 Sinography (Fistulography) for intestinogenital fistula.
 Hysterosalpingography (Lateral view) for diagnosis of vesicouterine fistula when there is
history of hematuria (Youssef’s Syndrome). „
 Ultrasound, CT and MRI are done for evaluation of complex fistulae. Where
involvement of ureter or intestines are there.
  Endoscopy studies: Cystourethroscopy is not routinely done. The added information is:
Exact level and location of the fistula and its relationship to ureteric orifices and bladder
neck.
 Examination under anesthesia is helpful for identification of small fistulae. A metallic
probe may be used for exploration.
 Three Swab Test
- Three cotton swabs are placed in the vagina—one at the vault, one at the middle and one
just above the introitus. The methylene blue is instilled into the bladder through a rubber
catheter and the patient is asked to walk for about 5 minutes. She is then asked to lie
down and the swabs are removed for inspection.

Observation Inference
Upper most swab soaked with urine Ureterovaginal fistula
but unstained with dye. The lower two
fistula swabs remain dry
Upper and lower swabs remain dry Vesicovaginal fistula
but the middle swab stained with dye
The upper two swabs remain dry but Urethrovaginal fistula
the lower swab stained with dye
Management
 Preventive

 Conservative

 Operative

 Nursing management

1) Preventive Management

 Obstetric fistula in the developing world can be prevented with safe motherhood
initiative (WHO-1987).

 Women with obstetric VVF is considered as a ‘near-miss’ maternal death.

 Gynecological fistula—can be prevented with better anticipation and improved surgical

skill.

 Obstetric Fistula

 Primary Prevention

 Availability of family planning method services

  Strategy to make motherhood safer should be followed

 Good antenatal care

 Trained birth attendants

 Transportation and emergency obstetric care

 Secondary Prevention

 Insert an in dwelling catheter and start continuous closed drainage

 Early recognition of CPD and prevention of obstructed labor

 LSCS in indicated cases

 Avoidance of difficult forceps and destructive operations

 Prolonged Catheter drainage in prolonged or obstructed labor

 Gynecological Fistula

 Immediate detection of bladder injury/ Ureter.

 Watertight closure of bladder.

 Avoidance of vaginal incision if possible after recognition of bladder injury

 Prolonged uninterrupted bladder drainage in postoperative period.

 Surgical Fistula

 Adequate exposure during surgery

 Minimize bleeding and hematoma formation

 Dissection in correct planes

 Cystourethroscopy during surgery

 Radiation Fistula

 Proper dose and technique of irradiation

 Packing of the vagina.

 Midline block

2) Conservative Management
 Indications

 Simple fistulae

 <1 cm in size

 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 fistula may resolve spontaneously

 If fistula decrease in size → drainage for additional 2-3 weeks

 If no improvement in 30 days will need surgery

3) Operative Management
 Pre-operative Management
 Preoperative assessment of status of fistula should be assessed.
 Urethral involvement should be assessed.
 Provide emotional support to the patient.
 Local infection in the vulva should be treated by application of silicone barrier
cream or glycerin.
 Urinary antiseptics at least 3-5 days prior to surgery.
 Definitive Surgery
 Time: The ideal time of surgery is after 3 months following delivery. By this
time, the general condition improves and local tissues are likely to be free from
infection. Further delay is likely to produce more fibrosis and unnecessary
prolongs the misery of the patient. Early repair may compromise the success.
Surgical fistula if recognized within 24 hours, immediate repair may be done
provided it is small. Otherwise it should be repaired after 10–12 weeks.
Radiation fistulae should be repaired after 12 months.
 Route of Repair: It mostly depends upon the access to the fistula site and the
tissue mobility of the vagina. Either the abdominal or vaginal route may be
approached according to the choice and expertize of the surgeon.
 Suture Material: Polygalactin (Vicryl) 2-0 suture material is preferred for both
the bladder and vagina. Polydioxanone (PDS) 4-0 on a 13 mm round bodied
 needle is used for the ureter. 3-0 PDS on a 30 mm round bodied needle is used
for bowel surgery.
 Saucerization: Saucerization is the closure of a small fistula using interrupted
stitches without dissection of bladder from the vagina. This may be employed in
a very small fistula using Vicryl (2-0).
 Latzke technique: Latzko technique is used to repair a VVF that develops
following total hysterectomy operation. Principle of this operation is to produce
partial colpocleisis (obliteration of the vagina around the fistula). This procedure
is suitable for a fistula which is small and high in the vagina.
 Use of graft: Repair of a big fistula may need inter position of tissue grafts to fill
space and with new blood supply. Different tissues may be used.
4) Nursing Management
 Pre-operative nursing care
 Maintain good interpersonal relationship with the patient.
 Obtain proper history of the patient.
 Provide pre-operative and post-operative teaching.
 Obtain preoperative test results.
 Provide emotional support to the patient.
 Administer preoperative medications
 Clean the surgical site.
 Post-operative nursing care
 Maintain proper positioning.
 Maintain airway.
 Tell patient to exercise.
 Maintain proper input and output charting.
 Administer medicines.
 Maintain input output charting.
 Provide proper dressing at the surgical site to prevent infection.
 Provide catheter care.
Reference
Bain, C.M., Burton, K., & Mcgavigan, C.J. (2011). Gynaecology Illustrated. Elsevier Ltd.
Blackwell, W. (2018). Dewhurst’s Textbook of Obstetrics & Gynaecology. John Wiley & Sons
Ltd.
Bradshaw, K., Corton, M., Halvorso,. L., Hoffma, B., Scharffer, J., Schorge, J. (2016). Williams
Gynaecology. New Delhi, Mc Graw Hill Education.
Dutta, D.C. (2016). Textbook of Gynecology Including Contraception. New Delhi, India: Jaypee
Brothers Medical Publishers Pvt. Ltd.