2. Definition
Abnormal communications between urinary
& genital organs.
Remember 2 golden rules
1st rule: urine may escape from
ureter tube, uterus, cervix, vagina
bladder tube, uterus, cervix, vagina
urethra always vaginal.
2nd rule in naming a fistula,
Part of the urinary tract is 1st to be described
7. Necrotic Obstetric Fistula
Prolonged compression of soft tissues between
head & brim of a narrow pelvis.
→ ischaemia, pressure necrosis & sloughing of
base of the bladder.
Urethra is also often involved.
Slough takes some days to separate
→ Incontinence develops 5-7 days after labour
Such fistulae are often surrounded by dense
fibrosis
8. Traumatic Obstetric Fistula
Direct injury to bladder wall by sharp
instrument (perforator or decapitation hook)
during a difficult labour
Forceps rarely cause it
Incontinence Appears immediately After
Labour
9. Traumatic Fistula
Surgical trauma: Bladder may be injured
during vaginal operation as anterior
colporrhaphy
during abdominal operations as hysterectomy.
Direct trauma: is a rare cause, but cases have
occurred as a result of impalement.
10. Other Causes
Inflammatory disease: result from
Bilharziasis of bladder
Tuberculosis of bladder.
A pelvic abscess may open into bladder & vagina
Malignant neoplasms:
As advanced carcinoma of cervix or of bladder, or
vagina
By direct invasion of the wall and ulceration.
Radium necrosis:
Sloughing of the bladder
As a complication of radium treatment used for cure of
malignant disease in pelvis
11. Symptoms
Incontinence of urine
Complete (large fistula) OR
Partial (small or high fistula)
DD: uretero-vaginal fistula.
Symptoms of vulvitis:
Pruritus, burning pain due to continuous
discharge of urine.
Cystitis
Due to ascending infection from vulva
12. Diagnosis
History of incontinence following labour or operation.
Several days after labour necrotic obstetric
fistula
Immediately after difficult labour traumatic
fistula.
Palpation of anterior vaginal wall:
Large fistula Can be felt
Small fistulas cannot be felt, but surrounding
fibrosis is usually palpable
13. Diagnosis
Inspection of the anterior
vaginal wall
In Sims’ position or left
lateral (semi-prone)
position
With the use of Sims’
speculum.
14. Diagnosis
For small and high fistula
Dye test: Injection of methylene blue into
bladder by a catheter to outline the fistula while
anterior vaginal wall is inspected by use of
Sim’s speculum.
DD: uretrovaginal fistula
Sometimes a metal catheter or sound is passed
through the urethra to appear at the fistulous
opening.
15. Management
Prophylaxis:
Antenatal:
Diagnosis of abnormalities that possibly result in fistula
formation
contracted pelvis
malpresentations
During labour
Diagnose and deal with:
prolonged labour
contracted pelvis
Malpresentations
Risky operations should all be avoided
high forceps
forceps with incompletely dilated cervix
risky destructive operations.
16. Management
If injury to the bladder is discovered during a
difficult labour,
Don’t suture the tear due to tissue oedema and
friability.
fix rubber catheter for 10 days
The tear may heal completely or be much smaller
If the injury is detected some time after labour, as
in cases of necrotic fistulas,
operations done except at least 3 months after delivery
to allow for maximum involution of the tissues.
17. Preoperative Preparation
Treat vulvitis:
Cover skin of the vulva, and inner thighs by a thick
layer of Vaseline, zinc oxide ointment or any bland
ointment, to prevent maceration of the skin by the
continuous discharge of urine.
Renal function tests:
Culture of urine,
if pathogenic organisms are found, patient is given
urinary antiseptics until urine is sterile.
18. Methylene blue test
to differentiate a small vesico-vaginal fistula from a
uretero-vaginal fistula.
3 pieces of gauze are placed in the vagina
200 cc of sterile fluid coloured with methylene blue is Injected
into the bladder
The lowest piece of gauze is discarded as it is usually
stained during filling the bladder.
If the middle or upper pieces stain → fistula is vesical
If none of the pieces stain and the upper one is wet with
uncoloured urine → fistula is ureteric.
If all are dry and unstained → excludes vesical or ureteric
fistula.
20. Cystoscopy
Determine relation of the fistula to ureteric openings in
bladder
Exclude multiple fistulas
Reveal associated bladder pathology.
Chromocystoscopy
IV Injection of 4 c.c. of 0.4%
indigocarmine solution
If kidney function is good →
Blue efflux from the ureter in 4
minutes.
21. Operation
flap-splitting operation, or dedoublement
Circular incision around the fistula.
The 2 short longitudinal cuts
upwards and downwards Long.
incision
Through the thickness or the vagina
but not the bladder.
→ 2 flaps of vaginal wall. Circular
incision
Free mobilization of the vaginal
Fistula
flaps from the bladder over a wide
area, at least 1.5 cms around the
fistula.
22. Operation
The hole in bladder is then closed by 2
layers of interrupted sutures going through
muscle wall only & not piercing the mucous
membrane.
The vagina is then closed by interrupted
sutures going through its whole thickness.
A rubber catheter is fixed in the urethra
Tight vaginal pack to prevent reactionary
haemorrhage.
23.
24. The saucerisation operation
(Sim’s operation)
Indicated
If tissues are too adherent and fibrosed to do flap
splitting
After failure of the flap splitting.
Technique:
Edge of the fistula is excised removing a wider part of
the vagina than of the muscle wall of the bladder
Edges of both organs are simultaneously coapted
together by the use of nonabsorbable sutures
Certain high fistulae are better treated by
abdominal (transperitoneal or transvesical) repair.
25. Postoperative Care
Recumbent position
The bladder should be constantly empty.
Fluids (3 litres/day).
Urinary antiseptics & antibiotics.
Vaginal pack is removed 24 hours after operation.
Catheter is removed after 10 days.
After its removal the patient is instructed to void urine
every two hours by day &
every four hours by night,
to avoid over-distension of bladder & disruption of suture line.
26. Subsequent Management
Patient is instructed to
avoid sexual intercourse for 3 months
avoid pregnancy for 1 year
Caesarean section is almost absolutely
indicated.
27. URETERO-VAGINAL FISTULA
Cause:
Injury to ureter during a gynaecological operation as
hysterectomy
may develop following a difficult labour.
It leads to incomplete incontinence
Urine from affected ureter escapes from vagina while
bladder fills up & empties normally from other ureter
It is always small & high up in vagina lateral to
cervix.
Differentiated from a vesico-vaginal fistula by:
by methylene blue test.
Cystoscopy shows ureteric efflux on one side only.
28. Prophylaxis
Ureteric injury can be avoided by
pre-operative intravenous pyelography
ureteric catheterization
proper surgical technique.
29. Treatment
Abdominal re-implantation of ureter into
bladder.
If not possible, ureter is transplanted into
sigmoid colon.
If kidney function is very poor on the
affected side → kidney can be sacrificed.
30. Kidney Function Tests
Blood urea: Normally 20-40 mg%.
Specific gravity of urine before and after water administration
(water concentration test):
Normally high before, low after
In chronic nephritis → low fixed S.G. of about 1010.
Urea concentration test: Normally urea in urine' should be 2%
or over after administration of 15 grams of urea by mouth.
Urea clearance test: It is a delicate test.
It indicates the no. of cm3 of blood cleared of urea per minute
Average = 70-120%
< 50% → renal impairment.
Intravenous pyelography.
31. Types Of Incontinence Of Urine
1. True incontinence genito-urinary fistula.
2. Stress (Sphincter) incontinence weakness of
Internal urethral sphincter.
3. Urgency incontinence severe inflammation
leading to marked irritation of bladder & so urge
to pass urine cannot be inhibited & some urine
will pass involuntary while patient is in her way to
W.C.
4. False incontinence retention with overflow
5. Nocturnal enuresis.
32. Causes Of Retention Of Urine
Cause of urinary retention is an impacted
pelvic mass.
Diagnosis is made clear by attention to
associated symptoms
33. Associated Conditions
Condition Diagnosis
Primary amenorrhea → Haematocolpos
Secondary amenorrhea → Retroverted gravid uterus
Menorrhagia → Uterine fibroid
No menstrual upset → Ovarian or broad ligament tumour
Irregular bleeding → (1) threatened abortion from a retroverted
gravid uterus,
→ (2) pelvic haematocele
→ (3) pelvic abscess
Labour → Descent of the foetus to from a pelvic
tumour
