1. Obstetrics fistula
 Genito-urinary fistula is an abnormal communication between the
urinary system (ureters, bladder, and urethra) and the genital syestem
(uterus, cervix, and vagina) systems.
 Global estimate is about 100,000 new cases per year.
 Its common cause (90%) in developing countries is obstructed labor.
 Ethiopia 97 % obstetric cause.
 One study showed 83.6% of cases of fistula occurred before age of
20yrs.
 54-60 % of them were divorced

2. Classification
 Method of classification is
based on anatomic position
of the communication.
 Fistulas can develop at any
point between the genital and
urinary systems.
 Vesicovaginal fistula(VVF)
is the most common among
others.

3. Etiology
Childhood
 Penetrating trauma.
 Female genital mutilation
 Early marriage
Obstetrics trauma
 Obstructed labour :the most common.
 Traumatic Forceps delivery
 Rupture of the uterus
 Pelvic Surgery (hysterectomy ,c/s )
Others
 Radiotherapy.
 Malignancy.

4. Mechanism
Pressure necrosis
 Compression between presenting part and posterior surface of the
pubis that leads to ischemic necrosis of the bladder neck and anterior
vaginal wall.
 Sometimes the anterior lip of cervix and trigone could be injured
 If the compression of soft tissues occurs posteriorly between sacral
promontry and presenting part necrosis of posterior vaginal wall and
underlying rectum occurs
 Injured areas slough between third and tenth day of puerperium

5. Clinical feature of VVF
 Continuous urine leakage vaginally occur in the 3-10 days of
procedures.
 Have foul ammoniac odor.
 Depression
 Insomnia
 Low self esteem
 Disrupted sexual relationship

6. Diagnosis
Hx
1. leakage of excessive volume of fluid per vagina with no voided
urine(VVF)
2. Small amount of urine leakage via vagina but has regular voiding
(Ureterovaginal fistula )
3. Leakage during and after voiding via vagina(Urethrovaginal
fistula)

7. Cont...
 Although direct observation is mainstay of diagnosis , Pinpoint
fistulas can be difficult to locate.
Three-swab test
 Bladder instillation of visually distinct solutions such as methylene
blue, sterile milk, or indigo carmine can often indicate the location.
 When the presence of a urinary fistula is uncertain or the location in the
vagina cannot be identified, a modified tampon test or three-swab test
is recommended

8. Cont...
 After the patient has engaged in 15 to 30 minutes of routine activity, the
gauze is removed serially from the vagina and inspected for presence of
dye.
 The specific gauze colored with dye suggests where in the vagina a
fistulous tract is located—a proximal or high location in the vagina for
the innermost gauze, and a low or distal fistula for the outer most ended

9. Cystourethroscopy
 It allows localization of the
fistula, determination of its
proximity to the urethral
orifices, and assessment of
surrounding bladder mucosa
viability.

10. Grave social consequence of fistula
are
 Divorce.
 Depression.
 Poverty.
 Suicide.

11. Treatment
Preoperative care
Schedule After three months for healing of
the
necrotized tissues around the hole
Treat any infection or inflammation.
Correct nutritional status.
Perineal skin care
Surgery
It is mainstay of treatment, vg approach.