GENITAL FISTULAE

PRESENTED BY
DR. JAMES ENIMI OMIETIMI
 INTRODUCTION
A fistula is an abnormal communication
between two (2) or more epithelial surfaces.
A genital fistula is an abnormal
communication between the genital tract
(vagina, cervix, uterus or perineum, in
decreasing order of frequency) and either the
urinary tract (urinary bladder, urethra or
ureter) or the gastrointestinal tract (rectum,
colon, anal canal or small bowel).
 INTRODUCTION
Continued.
Multiple or complex genital fistulae involving
the urinary and intestinal tract are regularly
seen: VVF with RVF.
Rarer forms of fistulae like salpingocolic
fistula following infection with tuberculosis
and actinomycosis which cause diagnostic
confusion and therapeutic difficulties have also
been reported.
 PREVALENCE
Varies from country to country and
continent to continent as causative
factors vary.

 UK; 120-350 per year

 Third World; about 700 per year
 UPTH; 9 out of 452 gynae admissions (annual
report of 2001)
 WHO estimate; 500 000 untreated cases
worldwide
 TYPES OF GENITAL
FISTULAE
 Anterior vaginal wall;
1. Vesicovaginal fistula (VVF)
2. Urethrovaginal fistula (UVF)
3. Sub-symphysial fistula
4. Bladder neck fistula
5. Mid-vaginal fistula
6. Juxta-cervical fistula
 TYPES OF G. FISTULAE contd.
 Posterior vaginal wall
1.Rectovaginal fistula (RVF)
2. Anovaginal fistula (AVF)
OTHERS
1.Vault fistula
2.Uretero-vaginal fistula
3.Vesico-cervical fistula
4Vesico-uterine fistula
5.Colo-uterine fistula
6.Salpingocolic fistula
 AETIOLOGY OF GENITAL FISTULAE
The aetiology of genital fistulae is varied and may be
broadly categorized into;
 Obstetric ( following prolonged neglected
obstructed labour) accounting for over 90% of
cases in developing countries.
 Traditional Surgical Practices; FGM, Gishiri cut

 Surgical (following pelvic surgery e.g. TAH)

accounting for over 70% of cases in developed
countries.
 Radiation to the pelvis for various reasons

 Malignancy within the pelvis

 Aetiology of G. Fistulae contd.

 Obstetric trauma following operative vaginal

delivery
1.Forcible rotation of the fetal head with kielland’s
forceps may injure the urinary bladder
2.Simpson’s perforator may injure the bladder
during craniotomy
3. Symphysiotomy may lead to injury to the neck of
the urinary bladder
 Aetiology of G. Fistulae contd.
 Infections
1.Schistosomiasis
2.Tuberculosis
3.Actinomycosis
4.Lymphogranuloma venereum
5.Measles
6.Noma vaginae
 Aetiology of G. Fistulae contd.
 Inflammation within the abdomen and
pelvis
1.Crohn’s Disease > colo-uterine fistula
2.Ulcerative Colitis > rectovaginal fistula
3.Diverticular Disease > colo-vaginal fistula
>colo-uterine fistula
 Aetiology of G. Fistulae contd.
 Miscellaneous
1.Coital Injury
2.Penetrating Trauma
3.Neglected Pessary
4.Other Foreign Bodies
5.Catheter Related Injuries
 CLINICAL PRESENTATION
 Patient may be depressed, malnourished, anaemic
 May present with foot drop & smell of urine
 Hx. –leakage of urine & or faeces over a period time
following delivery, surgery etc.
 Symptoms usually develop 5-14 days after injury
 Continuous urinary incontinence

obstetric and radiation fistulae

 Cyclical haematuria or menouria

vesico-uterine or vesico-cervical fistulae following

caesarean section
 watery vaginal discharge
 Clinical presentation contd.
 Stress incontinence
proximal urethrovaginal fistulae
 Postoperative urinary leakage, oliguria,
abdominal distension, pyrexia or loin pain
ureteric fistulae
 Offensive vaginal discharge, incontinence of
liquid stool and flatus
colo-vaginal and rectovaginal fistulae
 FINDINGS ON
CLINICAL
EXAMINATION
O\E -Ill looking, pale with evidence of inter
current infections
Abd. –kidneys may be enlarged & tender
Pelvic Exam. –vulva & thigh excoriations
(ammoniacal dermatitis)
 Clinical Examination contd.
 V/E –best performed in a lateral prone position
-digital to precede speculum exam.
-insert speculum of appropriate size
-visualize ant. Vaginal wall & then
-post. Vaginal wall
-Do digital rectal exam. to R\O RVF
 EXAMINATION UNDER
ANAESTHESIA
 Digital vaginal examination and examination
with a Sim’s speculum may not confirm or
exclude a fistula, thus necessitating examination
under anaesthesia.
 A malleable silver probe is passed through
openings in the vaginal wall;
-For VVF and UVF, a metallic click against a
silver catheter may be felt or seen via a
cystoscope.
-For RVF , the probe may be felt digitally in the
rectum or seen via a proctoscope.
 EUA Continued.
 Available access and the mobility of tissues
for vaginal repair is assessed.
 The decision to repair vaginally or an
abdominal approach can also be taken then.
 INVESTIGATIONS
 GENERAL
 FBC + Malaria Parasite + Widal Test
 Urine for urinalysis & m.c.s.
 Stool for Parasitic Infestations
 CXR
 Serum E/U/Cr
 Intravenous Urography
 INVESTIGATIONS contd.
Clinical examination and Examination Under
Anaesthesia may not conclusively confirm
or exclude the presence or absence of a
fistula. Further investigations are thus
necessary to confirm or exclude a fistula.
Investigations are also necessary for full
evaluation prior to deciding on treatment.
Further specific investigations done include;
SPECIFIC INVESTIGATIONS

 DYES STUDIES
 Investigations of first choice
 Confirm if discharge is urinary
 If leakage is extra-urethral rather than urethral
 To establish the site of leakage
 Phenazopyridine-200mg tds orally
 Indigo carmine- intraveneously
 Methylene blue instillation
 DYE STUDIES contd.
 Patient in lithotomy position
 Examination best done under direct vision
 ‘Three Swab Test’ has limitations and is not
recommended.
 Adequate distension of the urinary bladder
 If clear fluid leaks after instillation of dye,
ureteric fistula is likely.
 DYE STUDIES contd.
 Confirmed by ‘two dye test’
 Phenazopyridine to stain renal urine and
 Methylene blue to stain the bladder urine.
 Not very useful for intestinal fistulae;
However, oral carmine marker may be
useful
 Rectal air via a sigmoidoscope and vagina
filled with saline
OTHER SPECIFIC INVESTIGATIONS
 Cystoscopy – small vvf
 Cystography – vesico uterine fistulae (lat. view)
 Hysteroscopy/Hysteosalpingography-vesico
uterine fistulae ( lat. view)
 Fistulography –small intestinal fistulae
 Colpography –small fistulae involving vagina

 Endoanal Ultrasound, MRI –anorectal & perineal

fistulae
 Barium enema, Barium meal & follow through
-Intestinal fistulae above the anorectum
 PREOPERATIVE
TREATMENT
 Timing of definitive repair
 Improve Patient’s General Health; high protein
diet, antimalarials, antihelmintics, haematinics
& Rx infections
 Rx vulval dermatitis with silicone barrier
creams, zinc & castor oil
 Bowel Preparation
 Prophylactic Antibiotics
 REPAIR OF VVF

 Route of Repair; vaginal or abdominal

 Position of Patient; lithotomy or reverse
lithotomy (knee-elbow position)
 Type of suture materials; absorbable -vicryl
2/0 or chromic catgut 2/0
 Types of Repair;(1) Dissection & repair in
layers (2) Saucerization
 POST OPERATIVE
MANAGEMENT
 Fluid Balance; intake 3-4 litres per day
output 100-120mls/hr
 Bladder Drainage; check drainage & vol. of urine
hrly
 Post Operative antibiotics
 Prevention of Deep Vein Thrombosis
 Care of the perineum with vulva pads
 Duration of Drainage; 10-14 days on the average
 Retraining of urinary bladder before discharge
 Post Operative Mgt. Contd.
Instructions on Discharge
 EUA & dye test on day 21 before discharge

 Refrain from sexual intercourse for 3months

 Counsel for antenatal care & hospital delivery

in all subsequent pregnancies
 Elective Caesarean Section next pregnancy