(21) Genito-urinary Fistula
Transcript of (21) Genito-urinary Fistula
GENITO-URINARY FISTULAS
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
Varieties
1. Vesico-vaginal
2. Uretero-vaginal
3. Urethro-vaginal
4. Vesico-cervical
5. Uretero-cervical
6. Uretero-uterine
VESICOVAGINAL FISTULA(The Commonest)
Aetiology Congenital: very rare. Traumatic fistula
Obstetric trauma Necrotic obstetric fistula Traumatic obstetric fistula
Surgical trauma Direct trauma
Inflammatory disease Malignant neoplasms Radium necrosis
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
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
Traumatic Obstetric Fistula
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.
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
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
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
Diagnosis Inspection of the anterior
vaginal wall In Sims’ position or left
lateral (semi-prone) position
With the use of Sims’ speculum.
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.
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.
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.
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.
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.
Methyleneblue test
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.
Circular incision around the fistula. The 2 short longitudinal cuts
upwards and downwards Through the thickness or the vagina
but not the bladder. → 2 flaps of vaginal wall. Free mobilization of the vaginal
flaps from the bladder over a wide area, at least 1.5 cms around the fistula.
Operationflap-splitting operation, or dedoublement
Circularincision
Long.incision
Fistula
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.
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.
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.
Subsequent Management
Patient is instructed to avoid sexual intercourse for 3 months avoid pregnancy for 1 year
Caesarean section is almost absolutely indicated.
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.
Prophylaxis
Ureteric injury can be avoided by pre-operative intravenous pyelography ureteric catheterization proper surgical technique.
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.
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.
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 overflow5. Nocturnal enuresis.
Causes Of Retention Of Urine
Cause of urinary retention is an impacted pelvic mass.
Diagnosis is made clear by attention to associated symptoms
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