Genitourinary fistula

Presented by: Rohini Kashyap

Roll no. 18066
Mentor: Dr. Lalit Mahajan
 Content
• Definition
• Types
• Causes
• Clinical features
• Investigation and management
• Prevention
 Definition
A fistula is an abnormal communication between two or
more epithelial surfaces.
Genitourinary fistula is an abnormal communication
between the urinary and genital tract.
Either acquired or congenital
Involuntary escape of urine into the vagina
Incidence- approximately 0.2–1 percent among
gynaecological admissions
Types Bladder:
Vesicovaginal (commonest)
Vesicourethrovaginal
Vesicouterine
Vesicocervical.
Urethra:
Urethrovaginal.
Ureter:
Ureterovaginal
Ureterouterine
Ureterocervical
Vesicoureterovaginal
 Vesicovaginal fistula (vvf)

• There is communication between the

bladder and the vagina and the urine
escapes into the vagina causing true
incontinence

• This is the commonest type of

genitourinary fistula.
Types based on complexity
 Types based on site
• Juxtacervical - b/w supratrigonal region and vagina
• Midvaginal - b/w base(trigone) of bladder and vagina
• Juxtaurethral - b/w neck of bladder and vagina
• Subsymphysial - Circumferential loss of tissue in the region of
bladder neck and urethra. The fistula margin is fixed to the
bone.
 Causes
1). Obstetrical
-Ischemic
Obstructed labor
 Causes
1). Obstetrical
-Traumatic

-Instrumental vaginal delivery

-Destructive operations

-Abdominal operations
 Causes
2). Gynaecological
Operative injury: Colporrhapy, Hysterectomy

Traumatic: Fall on sharp object, Fracture of pelvic bone, Stick used

for criminal abortion, following RTA

Malignancy: Cervix, Vagina, Bladder

Infection: GTB, Lymphogranuloma venereum, Schistosomiasis,

Actinomycosis

Radiation
 Clinical features

• Symptoms :
• Continuous dribbling of urine per vaginam( True incontinence)
• No normal urination
• Associated pruritus vulvae
 Clinical features

• Signs:
• Vulval Inspection

1. Escape of watery discharge per vaginum of ammoniacal smell

2. Evidence of sodden and excoriation of vulval skin.

3. Varying degrees of perineal tear may be present.

 Clinical features
• Internal examination
• Speculum examination

A. Position- Sim’s

B. Size

1. Big- prolapse of bladder mucosa

2. Small- puckered area on the vagina

 Differential diagnosis

• Stress incontinence
• Ureterovaginal fistula
• Urethrovaginal fistula
Investigations
 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
• The patient is asked to walk for about 5 minutes.
• After lying down swabs are removed for inspection
Three swab test
 Treatment of vvf

Preventive Operative
 Preventive

• Obstetric fistula

1. Adequate ANC

2. Use of partogram

3. Continuous bladder drainage for 5-7 days

4. Adequate care to avoid injury during operative procedures

 Preventive
• Immediate management
• Continuous catheterisation (4-8weeks)- spontaneous closure of
small fistulas
• Unobstructed outflow tract - epithelialisation
• Team approach by gynaecologists, nursing staff and urologists
• Proper counselling
 Operative
Local repair of the fistula
• Preoperative assessment
• Preoperative preparations
• Definitive surgery.
 Preoperative assessment
• Fistula status— site, size, number, mobility and status of
the margins of the fistula.
• Urethral involvement - metal catheter introduced
through external urethral meatus into the bladder.
• Position of the ureteric openings in relation to a big
fistula-cystoscopy(Kelly’s air cystoscopy).
• Any associated rectovaginal fistula or complete perineal
tear.
• Complete hemogram and RFT
 Preoperative preparations

• Improvement of the general condition

• Treatment of local infection in the vulva- silicone
barrier cream or glycerine.
• Correction of urinary infection.
• Start urinary antiseptics - 3–5 days prior to surgery.
 Definitive surgery
Time of repair :
• ~3 months following delivery
• For uncomplicated (non-infected) fistula- without waiting for 3 months
Route of repair
• Abdominal
• Vaginal
Suture material
• Polygalactin( Vicryl) 2-0
Local repair by flap splitting method - preferred
 Principles of surgery
• Perfect asepsis and good exposure of the fistula.
• Excision (minimal) of the scar tissue round the margins.
• Mobilisation of the bladder wall from the vagina.
• Suturing the bladder wall without tension in two layers
• First layer - polygalactin (Vicryl) 2-0 suture on a 30 mm needle preferred.
Interrupted stitches (3 mm apart) excluding the bladder mucosa done.
• Second layer- interrupted sutures using the same suture material taking the
muscle and fascial layer of the bladder wall, burying the first suture line.
 Surgeries
• Saucerization (paring and suturing) : closure of a small fistula using interrupted stitches
without dissection of bladder from the vagina.
• Latzko technique :

Following total hysterectomy operation.

Principle - to produce partial colpocleisis (obliteration of the vagina around the fistula).
Suitable for a fistula which is small and high in the vagina.
• Use of graft: Inter position of tissue grafts to fill space and with new blood supply. Different
tissues may be used.
Martius graft: Bulbocavernous muscle and labial fat pedicle graft is used for big bladder neck
fistula.
Other tissues used are Gracillis muscle, omental pedicle graft (transperitoneal approach) or
peritoneal flap.
Laparoscopic repair
 Post operative care
Advice during discharge:
• To pass urine more frequently.
• To avoid intercourse - at least 3
months.
• To defer pregnancy - at least 1 year.
• If conception occurs - mandatory
antenatal check up and hospital
delivery.
• If repair fails, local repair should
again be attempted after 3 months.
 Principles in the management of gynaecological
vvf
• Detected during operation: Immediate repair in two layers.
• Detected in the postoperative period:
Indwelling catheter for about 10–14 days.
If fails, repair is to be done after 3 months.
• Malignant or post radiation fistula:
Ileal bladder
Anterior exenteration
Colpo- cleisis.
• Infective fistula: Eradication of the specific infection -followed by local repair.
“Thank you.”