Female Genital

Fistula
Objectives
At the of this session, you should be able to:
• Define fistula and describe its magnitude

• Explain etiology of fistula and pathogenesis of

obstetric fistula
• Describe all genital and extra-genital
complications of obstructed labor
Definition of Genital Fistula

• Fistula is an abnormal communication between

two hollow organs
• Genital fistula is a communication of the genital
organs (uterus, vagina) with the urinary tract
(urethra, bladder, ureter) and/or lower intestinal
tract (rectum, anus)
Magnitude of the Problem

• Prevalence and incidence:

– Exact figure unknown because of limited data
– Approximately 3 million cases worldwide, mostly
in sub-Saharan Africa
– 1.2 million fistula patients in Nigeria
– 26,800 fistula patients in Ethiopia
• Incidence:
– 2.2 per 1,000 births develop fistula
– 9,000 cases of fistula occur each year in Ethiopia
Etiology and Pathogenesis of Genital Fistula

1. Etiology of Genital Fistula: Obstetric Causes

Prolonged obstructed labor
Operative delivery:
 Cesarean section
 Cesarean hysterectomy
 Instrumental delivery
 Symphysiotomy
 Destructive delivery
2. Etiology of Genital Fistula: Non-Obstetric Causes

 Trauma:
Post-coital
Accidental fall
Female genital cutting
 Infection:
Granulomatous infection
Tuberculosis
 Pelvic surgical procedure
 Radiation
 Malignancy
 Congenital malformation
Pathogenesis of Obstetric Fistula

Prolonged obstructed labor

Pressure necrosis

Tissue slough

Fistula
Classification of Female Genital
Fistula
• Several attempts have been made, since the time of
Sims, but no consensus
• Hamlin: subjective assessment

• Waaldijk: continence mechanism and circumferential

damage Goh: size, scar and length of urethra
• Addis Ababa Fistula Hospital: two-stage
classification system
Classification System at Addis Ababa Fistula
Hospital
• Simple system with prognostic capacity

• Two-stage system for vesico-vaginal fistula: major class

and type
• Recto-vaginal fistula classified based on:

– Type of fistula

– Amount of healthy posterior vaginal wall left

– Distance of distal edge of RVF from anus

– Ability to reach proximal edge

 Classification of Vesico-Vaginal Fistula (VVF)
 Major class:
– 1: None circumferential, new VVF
– 2: None circumferential, previously operated VVF
– 3: Circumferential, new VVF
– 4: Circumferential, previously operated VVF
 Type according to urethral length:
– Type 1: Urethra not involved (4 cm or more)
– Type 2: Urethra involved but not the middle third (2.7 to 3.9 cm)
– Type 3: Middle third of urethra partly involved (1.4 to 2.6 cm)
– Type 4: Middle third of urethra completely involved but some
urethral tissue left (less than 1.4 cm)
– Type 5: No urethra
 Classification of VVF (cont.)

 Type according to bladder size:

Type 1: More than 7 cm

Type 2: 4 to 7 cm

Type 3: Less than 4 cm

 Type according to amount of healthy anterior vaginal wall

left:
Type 1: 3.5 cm or more
Type 2: Less than 3.5 cm
Type 3: Occluded
 Classification of Recto-Vaginal Fistula (RVF)
 Type of fistula:
• Type 1: None circumferential, new RVF
• Type 2: None circumferential, previously operated
RVF
• Type 3: Circumferential new, RVF
• Type 4: Circumferential, previously operated RVF
 Amount of healthy posterior vaginal wall left:
• 4.5 cm or more
• Less than 4.5 cm
• Occluded
 Classification of RVF (cont.)

 Distance of distal edge of RVF from anus and ability to reach

proximal edge of RVF:
– Proximal edge reachable, distal edge more than 3 cm from anus

– Proximal edge not reachable, distal edge more than 3 cm from

anus
– Proximal edge reachable, distal edge less than 3 cm from anus

– Proximal edge not reachable, distal edge less than 3 cm from

anus
Clinical Presentation of Fistula and Diagnostic
Workup
History
• Patient’s name, age, and address
• Current marital status
• Main problem and duration of problem
• Parity
• Number of living and dead children
• Social history
• Duration of labor
• Place of delivery (home/health institution)
Clinical Presentation and Diagnostic
Workup: History (cont.)
 Mode of delivery:
– Spontaneous vaginal delivery
– Instrumentation
– Forceps
– Vacuum
– Destructive
– Cesarean section
– Laparotomy
History (cont.)
• Outcome of pregnancy/delivery:
– Live birth
– Stillbirth
– Early neonatal death
• Complaint:
– Vaginal bleeding
– Vaginal discharge
– Unable to walk properly
– Menses not resumed
Physical Examination

 Assess general appearance:

– Gross nutritional status
– Developmental staging
– Mental status
 Take vital signs
 Examine whole system, but focus on:
– Respiratory and cardiovascular systems
– Abdominal, musculoskeletal, integumentary, and
central nervous systems
– Genito-urinary system (examine thoroughly)
 Physical Examination of Genital Region
• Examine external genital region for:
– Ulceration
– Excoriation
– Discharge
– Blood
– Deposits (e.g., stone or other foreign bodies in vagina)
– Female genital cutting
Physical Examination of Genital Region (cont.)

 Perform speculum and digital examination to assess:

– Extent of vaginal scarring
– Location, number, and size of fistula, and if circumferential
– Urethral length
– Size and degree of damage to bladder (see classification)
– Bladder stone
– Anal sphincter status and degree of damage to rectum (see
classification)
– Other problems
 Dye Test
• Dye test (three-swab test) used in pinhole fistula and to
localize hole:
– Place 50 ml of methylene blue into bladder using
Foley catheter
– Apply three cotton swabs to vagina
– Interpret results
• Interpretation of dye test:
– In uretero-vaginal fistula, upper swab stains only
with urine
– In vesico-vaginal fistula, middle swab stains with dye
– In urethral fistula, lower swab stains with dye
Laboratory Investigation
 Basic:
– Hemoglobin/hematocrit
– Blood group
– Rh
– VDRL
– Stool examination (for recto-vaginal fistula)
– Renal function
– Urinalysis (if possible)
 Optional:
– HIV
– Serum electrolytes
– Ultrasound of kidney, ureters, and bladder
 Management of Simple Vesico-Vaginal
Fistula
 Conservative Management of Vesico-Vaginal Fistula
 Bladder catheterization:
 Indicated for:
• Fistula diagnosed early after formation
• Small fistula
 Advantage:
• Continuous drainage
• Keeps bladder at rest
 Duration of catheterization: 2 to 3 weeks
 Delay surgery for 10 to 12 weeks for spontaneous healing
of fistula
Pre-Operative Care

 Complete physical examination of genitals:

– Check for healthy vaginal mucosa
– Check for genital skin infection
– Confirm classification of fistula
 Required laboratory investigations
• Counseling and consent
• Enema/laxatives, nothing by mouth
• Pre-anesthetic evaluation
• Prophylactic Antibiotics should be universal andDrug
of choice depends on sensitivity pattern of institution
 Basic Principles of Surgical Techniques
• Surgical approach:
– Vaginal
– Abdominal
• Patient positioning:
– Knee-chest
– Exaggerated lithotomy (widely used)
– Reverse Trendelenburg
 Basic Principles of Surgical Techniques (cont.)

 Equipment:
– Surgical instruments specific to fistula repair
– Ureteral and urethral catheters
 Type of suture material:
– Silk
– Chromic catgut: 0, 2-0, and 3-0
– Vicryl: 0, 2-0, and 3-0
 Anesthetize patient
 Clean and drape
Basic Principles of Surgical Techniques
(cont.)
 Close fistula :
 Trim edge of fistula
 Close fistula in two layers or single layer:
– First layer: interrupted 2-0 chromic catgut or Vicryl
– Second layer: continuous or interrupted 3-0 or 2-0 chromic
catgut or Vicryl
 Perform dye test
 Perform graft (not needed with simple VVF)
 Reconstruct vaginal mucosa
 Ensure bladder drainage:
– Foley catheter number 12, 14, or 16
– Secure catheter with tape
 Pack vagina
 Basic Post-Operative Care
 Immediate Post-Operative Care
• General status of patient
• Vital signs:
– Check every 30 minutes for 2 hours
– Then check every hour for 2 hours
– Then check every 4 hours
• Pain management:
– Pethidine
– Morphine
– Other drugs (tramadol hydrochloride, diclofenac
sodium, etc.)
Immediate Post-Operative Care

 Monitor fluid input and output

 Check drainage of catheter
 Watch for bleeding
 Manage fluids:
– Start fluids as early as possible/tolerated
– 3 liters of IV fluids
Late Post-Operative Care
 Check vital signs every 12 hours
 Remove vaginal pack in 24 to 72 hours
 Provide perineal care daily or as needed
 Manage catheter:
Ureteral:
• 7 to 10 days; irrigate daily or as needed using
normal saline or distilled water
Urethral catheter:
• 10 to 14 days; Irrigate daily or as needed using
normal saline or distilled water
Late Post-Operative Care (cont.)

• Manage fluids/diet:
– Encourage 3 to 5 liters of fluid by mouth daily
(drink until urine is colorless)
– Allow regular diet after 24 hours
• Encourage exercise and ambulation:
– Physiotherapy in bed
– Encourage walking after removal of vaginal pack
• Perform dye test if indicated
Late Post-Operative Care (cont.)

• Clamp catheter before removal to:

– Check for small fistula
– Improve bladder sensation and stretching
• Remove stitches if necessary on 14th day
• Conduct discharge assessment and provide
advice
Management of Recto-Vaginal Fistula
 Pre-Operative Management
 Perineal Care
 Treat ulceration and maceration of skin of vulva and
perineum:
– Douche, sitz bath
– Apply zinc oxide ointment or creams containing lanolin
 Treat active vaginal or cervical infection
 Laboratory Investigations
 Bowel Preparation
– Tap water enema for two days before surgery
– NPO after midnight on the day immediately before surgery
  Temporary Diversion
 Indications:
• Large and/or very high recto-vaginal defects (> 4 cm)
• Ongoing inflammation/infection and previous failed repairs
• Radiation-induced fistulas
• Significant scarring around fistula site
• Requires counseling, locating site of stoma, and colostomy
health education
• Often formed from descending/sigmoid colon
• Facilitates resolution of inflammation and healing
• Timing of surgery after diversion depends on resolution of
infection and inflammation
  Medication
• Begin use of estrogen creams weeks before surgery for
post-menopausal women
• Single dose of broad-spectrum prophylactic antibiotic:
– Erythromycin 500 mg by mouth TID
– Or neomycin 1 g by mouth the day before surgery
Repair of Simple RVF

 General Principles of Repair

• Ensure good exposure
• Ensure aseptic technique
• Localize fistula and determine size
• Ensure adequate mobilization
• Avoid rectal mucosa during closure
• Use tension-free closure
• Secure hemostasis
Surgical Techniques

• Position, clean, and drape patient

• Ensure maximum access
• Use circular incision around fistula edge
• Adequately dissect vaginal wall from underlying
rectal wall
• Excise scar from fistula edge
• Close fistula with 2-0 Vicryl starting from edge,
avoiding rectal mucosa
Surgical Techniques (cont.)

• Use atraumatic needle

• First layer closure can be continuous
• Second layer closure should be interrupted with 3-0
Vicryl
• Approximate lower portion of puborectalis and
external anal sphincter muscles
• Approximate vaginal wall with 3-0 Vicryl
Surgical Techniques for Repair of Complicated
Fistula
 Repair of Circumferential RVF
• Diversion colostomy is necessary before repair
• Identify proximal and distal edges
• Check for patency/stricture of rectal lumen at both edges
• Incise around fistula edges
• Mobilize circumferentially and adequately
• Approximate posterior wall of rectum
• Insert rectal tube under direct vision to avoid disruption
of repaired site
• Complete closure following other principles of recto-
vaginal fistula repair
 Repair of High RVF
• Re-evaluate to determine:
– Approach (use vaginal approach if proximal edge is
accessible)
– Need for temporary diversion
 Vaginal Approach
• Grasp posterior lip of cervix with Allis forceps and pull gently
up and forward
• Make incision around edge of proximal end of fistula
• May need to open pouch of Douglas
• Mobilize rectum adequately and pull downward
• Division of stricture may be required
• Mobilize distal edge the same way
• Same principles for closure
Post-Operative Care of RVF

• General principles are same as for VVF

repair
• Morphine is preferred in first 24 hours
because it slows peristalsis
• Mobilize rectum adequately and pull
downward
• Division of stricture may be required
• Mobilize distal edge the same way
• Same principles for closure
Post-Operative Care of RVF (cont.)

• If woman has a colostomy, resume regular diet

with bowel movement
• Keep rectal tube in situ for 10 or more days
• Avoid constipation; laxatives may be needed
• Assessment of Cure
• History, Physical examination, including vaginal
and rectal examination
• Rectal dye test at 15 days
Reversal of Colostomy

• Reverse colostomy when:

– Cure is ascertained
– State of continence is acceptable
– Or additional surgery is not an option
• Minimum of four weeks is trialed before considering
reversal (examination of tissue four weeks after
surgery)
• Similar pre-operative bowel preparation required
before reversal
Psychosocial Consequences of Fistula

• Social isolation

• Divorce

• Depression

• Suicide
Assignment

Complications and Prognosis of Fistula

 Intra-Operative Complications and
Management
 Immediate Post-Operative Complications
and Management
 Late Post-Operative Complications and
Management
 Prognosis of Fistula Repair