GENITAL TRACT INJURIES,

3RD DEGREE PERINEAL TEAR,

VVF, RVF
EXTERNAL GENITALIA
INTERNAL GENITALIA
 Genital Injury

It is the injury of the genital organ which

causes damage , loss of sustained, harm,
hurt to the patient.
 FEMALE GENITAL
TRACT INJURY
Obstetric Trauma
• Blunt
• Penetration
Gynecologic Trauma
• Blunt
• Penetration
OBSTETRICS(uterus)

LACERATION OF
CERVIX, VAGINA &
VULVA COMMONLY
OCCUR DURING
CHILDBIRTH
 RISK FACTORS

 Nulliparity
 Large baby
 Precipitous birth
 Operative delivery
 Episiotomy.
BASIC RULES OF MANAGEMENT

Resuscitation

Repositioning

Evaluation
 DELIVERY TRAUMA
• Perineal Lacerations – involves the fourchette,
perineal skin & vagina(1st, 2nd, 3rd & 4th degree
perineal tears)
• Vaginal laceration- involving the middle or upper
third of the vagina.
• Puerperal hematoma- it consist of venous &
arterial rupture of branches of the vaginal &
internal pudendal arteries.
 GYNECOLOGICAL TRAUMA

Causes: Foreign body , Sexual assault ,

Hematoma
Management :
Foreign objects stuck in the vagina or anus
• Keep the patient calm.
• Do not attempt to remove any foreign object
• Do not let the patient walk
• Transport with knees-flexed, legs-together.
 LACERATIONS

• Use local pressure to control bleeding.

• Hold dressings in place with diaper-type
bandage
• Do not pack dressings into vagina.
COMPLETE PERINEAL TEAR
 DEFINITION
• Complete perineal tear is the perineal tear
where in the entire perineum is torn with the
sphincter ani-externus being also ruptured.
There is also varying degree rupture of anterior
wall of the anal canal and rectum.
 CAUSES
OBSTETRIC INJURY TRAUMATIC INJURY
• It results from the badly • fall or operations for
managed second stage hemorrhoids, rectal
of labor by forceps fistula.
delivery for occipito –
posterior position or
extraction of after
coming head in breech
delivery.
 Obstetric legacies leading to major
gynaecological problems
• Pelvic organ prolapsed, Perineal injuries
• Genitourinary and rectovaginal fistula
• Anal incontinence
• Tender perineal and vaginal scar
• Eversion cervix with cervicitis
CLASSIFICATION
 3 RD DEGREE PERINEAL TEAR

A Perineal tear is a laceration of the skin

and other soft tissue structures along with
anal sphincter.
RISK FACTORS OF 3 DEGREE TEARRD

• Primigravida
• Big baby
• Face to pubis delivery
• Midline episiotomy
• Contracted pelvic &CPD
• Shoulder dystocia
• Precipitate labour
• Scar in the perineum
• Prolonged second stage
 SYMPTOMS
• Inability to control of flatus , feaces
• Dysparunia
• Diarrhoea
• Utero-vaginal prolapse
• No symptoms sometimes, detected in the routine
examination
 SIGNS
PER VAGINAL EXAMINATION
• Inspection There is absence of perineum; the vaginal
introitus and the anus almost open together. In extensive
tear, red rectal mucosa is found to prolapse through the
anal opening.
• Palpation: Bimanual vaginal examination should palpate
the vagina and pelvic organs as a routine.
• Rectal palpation: The anus and the anal canal is found to
be separated from the vagina by the recto vaginal septum.
• Differential diagnosis: Recto-vaginal fistula is the important
condition which may produce like symptoms.
 MANAGEMENT
• Perineorrhaphy
 TREATMENT
Perineorraphy:

Pre-
operative Operative Post –
operative

Incision
Dissection
Repair
 PRE-OPERATIVE PREPARATIONS

• Admitted a few days before the operation

• Clinical assessment of health status & local
perineal condition.
• Low residual diet before operation.
• Laxative is given 2 days before operation
• Bowel antiseptics are given
• On the evening before the operation , vulva is
shaved , bowel wash, savlon vaginal douche are
given.
• On the operation day , NPO till 8 hours after surgery.
PERINEORRHAPHY OPERATION
 POST OPERATIVE CARE
• Inj pethidine 75mg
• Care of bladder
• Diet
• Care of bowel
• Care of the perineal wound
• Position
• Advice-on-discharge
 HEALTH EDUCATION
To ease discomfort while recovering:
• Sit on a pillow or padded ring.
• Cool the wound with an ice pack, or place a chilled witch hazel
pad between a sanitary napkin and the wound.
• Use a squeeze bottle to pour warm water on your perineum as
you're passing urine.
• Sit in a warm bath just deep enough to cover your buttocks
and hips (sitz bath) for five minutes. Use cold water if you find
it more soothing.
• Take an over-the-counter pain reliever. Ask health care
provider about a numbing spray or cream, if needed.
• Talk to health care provider about using a stool softener or
laxative to prevent constipation.
GENITO-URINARY FISTULA
TYPES
VESICOVAGINAL FISTULA
 DEFINITION
• Definition. Vesicovaginal fistula (VVF) is an
abnormal opening between the bladder and
the vagina that results in continuous and
unremitting urinary incontinence.
 CLASSIFICATION
• Simple fistulas small in size (≤0.5cm)
• Complex fistulas large-sized (≥2.5 cm)
• Intermediate-sized Fistulas (between 0.5 and
2.5 cm)
 ETIOLOGY
• BLADDER INJURY (75%)
• PROLONGED LABOUR
• INSTRUMENTAL DELIVERY
• OBSTRUCTED LABOUR INJURY COMPLEX (urethral
loss, stress incontinence, hydroureteronephrosis,
renal failure, rectovaginal fistula, rectal
atresia, anal sphincter incompetence, cervical
destruction, amenorrhea,
pelvic inflammatory disease, secondary infertility,
vaginal stenosis, osteitis pubis, and foot drop)
 SIGN AND SYMPTOMS
• Constant urinary drainage per vagina
• Perineal skin irritation
• Recurrent cystitis
• Vaginal fungal infections
• Rarely pelvic pain
• Patients may not void at all and simply have
continuous leakage of urine into the vagina.
 DIAGNOSTIC EVALUATION
• History.
• Physical examination.
• A double dye test
• Urine culture and urine analysis
• Cystoscopy
• Voiding cystourethrography
• Intravenous urography and/or retrograde
pyeloureterography
• Cross-sectional pelvic imaging
`
Voiding cystourethrography
Intravenous urography and/or retrograde pyeloureterography
 TREATMENT

Nonsurgical management

Surgical management
 Nonsurgical management.

• Catheter drainage: Antibiotics and topical

estrogen creams are adjuvant measures to
prevent infection and promote healing.
• Fulguration of the fistula followed by catheter
drainage in small (<5 mm), uncomplicated
fistulas.
• Adjuvant measures such as fibrin glue with
fulguration and catheter drainage as a “plug”
in the fistula to allow the ingrowth of healthy
tissue.
Cont….
• Injection of platelet-rich plasma it is injected
around the fistula which occludes the fistula
mechanically, meanwhile, the growth factors
derived from platelets stimulate fibrosis and
neovascularization.
• Bilateral percutaneous nephrostomies and
ureteric occlusion it is often performed as a
palliative procedure in patients with malignant
VVF, poor performance status and limited life
span due to the advanced stage of the disease.
Bilateral percutaneous nephrostomies and
ureteric occlusion
 Principles of Vesicovaginal Fistula Repair
1. Adequate exposure of the fistula tract with debridement of devitalized and
ischemic tissue
2. Removal of involved foreign bodies or synthetic materials from region of
fistula, if applicable
3. Careful dissection and/or anatomic separation of the involved organ cavities

4. Watertight closure
5. Use of well-vascularized, healthy tissue flaps for repair (atraumatic handling
of tissue)
6. Multiple layer closure
7. Tension-free, nonoverlapping suture lines
8. Adequate urinary tract drainage and/or stenting after repair
9. Treatment and prevention of infection (appropriate use of antimicrobials)
10. Maintenance of hemostasis
 Surgical management
TRANSVAGINAL APPROACH TRANSABDOMINAL APPROACH
CONSERVATIVE METHODS – NEWER TRENDS

CBD
PCN & and Fulguration of
ureteric the fistula tract
occlusion

Injection of
Fibrin glue
platelet-rich
injection plasma
 Abdominal Versus Trans-vaginal Repair of
Vesico-vaginal Fistula
Abdominal Transvaginal
Length of hospitalization 4-7 days 1-2 days

Timing of repair Usually delayed 2–6 May be done immediately

months from the time of in the absence of infection
initial injury

Location of ureters relative Fistula located near Reimplantation may not be

to fistula tract ureteral orifice may necessary even if fistula
necessitate reimplantation tract is located near
ureteral orifice

Sexual function No change in vaginal depth Potential risk of vaginal

shortening or stenosis
Location of fistula Fistula located low on the Fistula located high at the
tract/depth of vagina trigone or near the bladder vaginal cuff may be
neck may be difficult to difficult to expose
expose
 Abdominal
Use of adjunctive Omentum,
flaps peritoneal flap,
intestine
Relative indications Large fistulas, located
high in a deep vagina,
radiation fistulas, failed
transvaginal approach,
small capacity bladder
requiring augmentation,
need for ureteral
reimplantation, inability
to place patient in the
lithotomy position
Transvaginal
Labial fat pad
(Martius fat pad),
peritoneal flap,
gracilis muscle, labial
myocutaneous flap
Uncomplicated fistulas,
low fistulas Vaginal
exposure may be difficult
in some nulliparous
patients
 RECTO-VAGINAL FISTULA(RVF)
• Definition: It is the fistulous communication
between vagina and the rectum or anal canal.
CAUSES • Injury during childbirth
• Crohn's disease or other
inflammatory bowel
disease
• Radiation treatment or
cancer in the pelvic area
• Complication following
surgery in the pelvic area
• Others
 CLASSIFICATION
• SMALL- fistulas less than 2.5 cm in diameter
• LARGE- fistulas more than 2.5 cm in diameter
• LOW FISTULAS- Low rectovaginal fistula is located
between the lower third of the rectum and
the lower half of the vagina.
• HIGH FISTULAS- A high fistula is located between
the middle third of the rectum and the posterior
vaginal fornix.
• MIDDLE FISTULAS- Middle fistulas are found
between the two.
 SYMPTOMS
• Passage of gas, stool or pus from your vagina
• Foul-smelling vaginal discharge
• Recurrent vaginal or urinary tract infections
• Irritation or pain in the vulva, vagina and the
area between your vagina and anus
(perineum)
• Pain during sexual intercourse
 DIAGNOSTIC EVALUATION
• History collection
• Physical examination
It includes inspecting vagina, anus and the area
between them (perineum) with a gloved hand.
Unless the fistula is very low in the vagina and
readily visible, examiner may use a speculum to
see inside vagina. An instrument similar to a
speculum, called a proctoscope, may be inserted
into anus and rectum to check for problems.
 Tests for identifying fistulas
• Contrast tests (barium enema)
• Blue dye test
• Computerized tomography (CT) scan
• Magnetic resonance imaging (MRI)
• Anorectal ultrasound
• Anorectal manometry
• Other tests
 TREATMENT
Medications
• Antibiotics. If the area around fistula is
infected, patients may be given a course of
antibiotics before surgery. Antibiotics may also
be recommended for women with Crohn's
disease who develop a fistula.
• Infliximab. Infliximab (Remicade) can help
reduce inflammation and heal fistulas in
women with Crohn's disease.
 SURGERY
• Sewing an anal fistula plug or patch of biologic tissue into
the fistula to allow tissue to grow into the patch and heal
the fistula.
• Using a tissue graft taken from a nearby part of your body
or folding a flap of healthy tissue over the fistula opening.
• Repairing the anal sphincter muscles if they've been
damaged by the fistula or by scarring or tissue damage
from radiation or Crohn's disease.
• Performing a colostomy before repairing a fistula in
complex or recurrent cases to divert stool through an
opening in your abdomen instead of through your rectum.
 What is Stromal-Vascular Fraction (SVF)?

• A new method of treatment of rectovaginal

fistula is based on the use of a stromal-
vascular fraction (SVF).
SVF is a cell product obtained from the
patient's own adipose (fat) tissue and then
injected into the wall between rectum and
vagina and surrounding tissues.
Cells of SVF help to:
• Stimulate Blood
Circulation
• Reduce Inflammation
• Reduce The Immune
Response
 COMPLICATIONS
• Uncontrolled loss of stool (fecal incontinence)
• Hygiene problems
• Recurrent vaginal or urinary tract infections
• Irritation or inflammation of your vagina,
perineum or the skin around your anus
• An infected fistula that forms an abscess, a
problem that can become life-threatening if not
treated
• Fistula recurrence
 LIFESTYLE AND HOME REMEDIES

• Wash with water

• Avoid irritants
• Dry thoroughly
• Avoid rubbing with dry toilet paper
• Apply a cream or powder
• Wear cotton underwear and loose clothing
 NURSING MANAGEMENT
• Fistula source
• Pain
• Fistula opening
• Location
• Length and width
• Perifistular skin integrity (Intact, Impaired)
• Abdominal contours and proximity of fistula to:
scars, skin folds, bony prominences, drains, or
ostomies
• Output/effluent
 NURSING DIAGNOSIS
1.Low Self-Esteem related to genitourinary problem
secondary to disease process as evidenced by urinary
incontinence.
2. Impaired urinary elimination related to disease process.
3 .Constipation/Diarrhea related to disease process as
evidenced by verbal communication
4. Sexual Dysfunction related to fistula, pain, as evidenced
by verbal communication
5. Deficient Knowledge regarding disease process,
prognosis as evidenced by facial expression
 NURSING THEORY
APPLICATION
• Orem’s Nursing system theory application
 Supportive education system

 Partial compensatory system

 Wholly compensatory system

• Accomplishes self –care Regulates the exercise
and development of self care agency

Supportive education
system
Supportive educative system
• Performs some self care measures for mother
• Compensates for self care limitations of the mother
• Assists the mother as required
• Perform some self care measures

• Regulate self-care agency

• Accepts care and assistance from the nurse

Partially
compensatory
system
• Accomplishes mother’s therapeutic self care
• Compensates for the mother’s inability to
engage in self care
• Supports and protects the mother
Wholly co
Wholly
compensatory
system
 JOURNAL PRESENTATION:
• Perineal body length as a risk factor for
ultrasound-diagnosed anal sphincter tear at
first delivery
Author:
E. J. Geller,B. L. Robinson, C. A. Matthews,
K. P. Celauro, G. C. Dunivan, A. K. Crane,
A. R. Ivins,P. C. Woodham, J. R. Fielding
• 73subjects completed the study.
• Mode of delivery was 69.9 % spontaneous
vaginal, 15.1 % operative vaginal, and 15.1 %
labored cesarean.
• In the vaginal delivery group 16.4 % (10 out of 61)
had a sphincter tear, compared with 8.3 % (1 out
of 12) in the labored cesarean group (p = 0.68).
• Women with PB < 3 had a significantly higher
rate of ultrasound-diagnosed anal sphincter tear
(40.0 % vs 11.1 %, p = 0.038).
• When comparing women with and without
sphincter tear, there was a significant difference
in mean antepartum PB (3.1 vs 3.7 cm, p = 0.043).
• Conclusions
A shortened perineal body length in
primiparous women is associated with an
increased risk of anal sphincter tear at the
time of first delivery.
SUMMARY
CONCLUSION