VESICO-VAGINAL VESICO-VAGINAL FISTULAFISTULA

PRESENTED BY PRESENTED BY

DR. ESTHER ENYINDAHDR. ESTHER ENYINDAH

INTRODUCTI0NINTRODUCTI0N

A fistula is defined as an abnormal A fistula is defined as an abnormal communication between two or more epithelial communication between two or more epithelial surfaces.surfaces.

The common gynaecological fistulae are:The common gynaecological fistulae are:

-VVF, RVF and UVF. VVF being the commonest.-VVF, RVF and UVF. VVF being the commonest.

VVF is a pathological communication between VVF is a pathological communication between the bladder mucosa and vaginal epithelium which the bladder mucosa and vaginal epithelium which allows free and continuous flow of urine from the allows free and continuous flow of urine from the bladder to the vagina such that the woman is wet bladder to the vagina such that the woman is wet all the time.all the time.

EPIDEMIOLOGYEPIDEMIOLOGY

Real incidence –unknown.Real incidence –unknown.Related to socio-economic status in the comm.Related to socio-economic status in the comm.More in teenagersMore in teenagersMore in primiparaMore in primiparaAccounts for 7% of Gynae. consultations in Accounts for 7% of Gynae. consultations in northern parts of Nigeria.northern parts of Nigeria.UPTH, accounted for 9 out of 452 (1%) Gynae. UPTH, accounted for 9 out of 452 (1%) Gynae. Admissions in 2001 (Annual Report)Admissions in 2001 (Annual Report)WHO estimates 500,000 untreated cases of VVF WHO estimates 500,000 untreated cases of VVF worldwide. worldwide.

AETIOPATHOLOGYAETIOPATHOLOGYVVF could be congenital or acquired.VVF could be congenital or acquired.In most third world countries, > 90% of fistulae are of obstetric In most third world countries, > 90% of fistulae are of obstetric aetiology whereas in United Kingdom, >70% follow pelvic aetiology whereas in United Kingdom, >70% follow pelvic surgery.surgery.

1. 1. Prolonged obstructed labourProlonged obstructed labour : Commonest cause of VVF in : Commonest cause of VVF in our environmentour environment

-Accounts for >80% of the cases.-Accounts for >80% of the cases.2. 2. Caesarean sectionCaesarean section:: -Incision involving the posterior bladder wall.-Incision involving the posterior bladder wall. -During reflection of the bladder.-During reflection of the bladder. -Accidental passage of a suture through the posterior -Accidental passage of a suture through the posterior bladder wall during repair of the incision.bladder wall during repair of the incision.3. 3. Uterine ruptureUterine rupture:: -Rupture of a previous caesarean section scar.-Rupture of a previous caesarean section scar. -Rupture of the unscarred uterus from obstetric manipulations.-Rupture of the unscarred uterus from obstetric manipulations. -The bladder may be caught in the sutures during repair.-The bladder may be caught in the sutures during repair.4. 4. Direct trauma during operative vaginal deliveryDirect trauma during operative vaginal delivery:: Forceps delivery, craniotomy, symphysiotomy, repair of vaginal Forceps delivery, craniotomy, symphysiotomy, repair of vaginal

or cervical lacerations.or cervical lacerations.

AETIOPATHOLOGY CONTD.AETIOPATHOLOGY CONTD.

5. 5. Gynaecological operationsGynaecological operations::

-Pelvic floor repair, vaginal hysterectomy, -Pelvic floor repair, vaginal hysterectomy, abdominal hysterectomy, colporrhaphyabdominal hysterectomy, colporrhaphy

-Commonest cause of VVF in developed -Commonest cause of VVF in developed countries, where it accounts for 75.3%countries, where it accounts for 75.3%

-Accounts for only 2.5% of VVF in Nigeria.-Accounts for only 2.5% of VVF in Nigeria.

-Risk factors for post operative fistulae are -Risk factors for post operative fistulae are as shown below.as shown below.

Risk factors forRisk factors for post operative fistulae. post operative fistulae.

Risk factorRisk factor PathologyPathology Specific e.g.’sSpecific e.g.’s

1.Anatomical 1.Anatomical distortiondistortion

Fibroids, Ovarian Fibroids, Ovarian massmass

2.Abnormal tissue 2.Abnormal tissue adhesionsadhesions

InflammationInflammation

Pelvic surgeryPelvic surgery

MalignancyMalignancy

InfectionsInfections

EndometriosisEndometriosis

C/S, Vag-Hys.C/S, Vag-Hys.

ColporrhaphyColporrhaphy

3. Impaired 3. Impaired vascularityvascularity

Ionizing Ionizing radiationradiation

Preop. Preop. RadiotherapyRadiotherapy

4. Compromised H4. Compromised H Anaemia,Nutri def.Anaemia,Nutri def.

AETIOPATH. CONTD.AETIOPATH. CONTD.

6. Radiation necrosis.6. Radiation necrosis.7. Malignancies: Ca Cervix, vagina, rectum and bladder.7. Malignancies: Ca Cervix, vagina, rectum and bladder.8.Traditional practices: Gishiri cut, circumcision, caustic 8.Traditional practices: Gishiri cut, circumcision, caustic

soda.soda. -Gishiri cut accounts for 10-13% of all cases of VVF in -Gishiri cut accounts for 10-13% of all cases of VVF in

the northern Nigeria.the northern Nigeria.9. Infections: Lymphogranuloma venerum, 9. Infections: Lymphogranuloma venerum,

schistosomiasis, tuberculosis.schistosomiasis, tuberculosis.10. Social factors: Early marriage and early delivery.10. Social factors: Early marriage and early delivery. ->50% of cases in northern Nigeria are below 20 yrs.->50% of cases in northern Nigeria are below 20 yrs. ->50% are in their first pregnancy.->50% are in their first pregnancy.11.Others: Coital injuries, excision of a urethral 11.Others: Coital injuries, excision of a urethral

diverticulumdiverticulum. .

Aetiology of fistulae in NE England Aetiology of fistulae in NE England and SE Nigeriaand SE Nigeria

AetiologyAetiology England (n=85)England (n=85) Nigeria (n=2,485)Nigeria (n=2,485)

1.Obstetric1.Obstetric

-Obstr.labour-Obstr.labour

11.8%11.8%

1.2% 1.2%

93.3%93.3%

81.4%81.4%

2. Surgical2. Surgical

-Abd. hyst. -Abd. hyst.

75.3%75.3%

42.4% 42.4%

2.5%2.5%

0.8%0.8%

-Vag. hyst.-Vag. hyst. 2.4%2.4% 0.6%0.6%

3. Radiation3. Radiation 10.5%10.5% 0.0%0.0%

4.Malignancy4.Malignancy 0.0%0.0% 2.0%2.0%

5.Miscellaneous5.Miscellaneous 2.4%2.4% 2.2%2.2%

TOTALTOTAL 100%100% 100%100%

CLASSIFICATIONCLASSIFICATION

VVF are classified according to the site of injury;VVF are classified according to the site of injury;Juxta-urethral fistulaJuxta-urethral fistulaMid-vaginal fistulaMid-vaginal fistulaJuxta-cervical fistulaJuxta-cervical fistulaVery large fistulaVery large fistulaVault fistulaVault fistulaCombined fistulaCombined fistulaCircumferential fistulaCircumferential fistulaResidual fistulaResidual fistula

CLINICAL PRESENTATIONCLINICAL PRESENTATIONTypical history is that of total incontinence soon after Typical history is that of total incontinence soon after a prolonged obstructed labour, operative vaginal a prolonged obstructed labour, operative vaginal delivery, or caesarean section.delivery, or caesarean section.In direct surgical injury to the bladder, the leakage of In direct surgical injury to the bladder, the leakage of urine may occur from day one.urine may occur from day one.Most surgical and obstetric fistulae symptoms Most surgical and obstetric fistulae symptoms develop between 3 or 5 – 14 days.develop between 3 or 5 – 14 days.In a review of cases from Nigeria, the average time In a review of cases from Nigeria, the average time for patient presentation was >5yrs. And in some for patient presentation was >5yrs. And in some cases, >35yrs. after the causative injury.cases, >35yrs. after the causative injury.History of previous surgeries or prolonged obstructed History of previous surgeries or prolonged obstructed labour. labour. Secondary amenorrhoea.Secondary amenorrhoea.Secondary infertility.Secondary infertility.

MANAGEMENT OF VESICOVAGINAL-MANAGEMENT OF VESICOVAGINAL-FISTULAFISTULA

by Dr. JAMES ENIMI OMIETIMI by Dr. JAMES ENIMI OMIETIMI

HistoryHistory

Clinical ExaminationClinical Examination

InvestigationsInvestigations

TreatmentTreatment

Clinical Presentation Clinical Presentation Hx. of previous pelvic or abdominal surgeryHx. of previous pelvic or abdominal surgery

Symptoms develop early, may be Day 1Symptoms develop early, may be Day 1

Postoperative urinary leakage, oliguria, Postoperative urinary leakage, oliguria, abdominal distension, pyrexia or loin painabdominal distension, pyrexia or loin pain

Present earlier for repair than obstetric casesPresent earlier for repair than obstetric cases

Hx. of previous unsuccessful attempt(s) at Hx. of previous unsuccessful attempt(s) at repair repair

FINDINGS ONFINDINGS ONCLINICAL EXAMINATIONCLINICAL EXAMINATION

O\E -Ill looking, malnourished, pale O\E -Ill looking, malnourished, pale with evidence of inter current with evidence of inter current

infectionsinfections

Abd. –kidneys may be enlarged & Abd. –kidneys may be enlarged & tendertender

Pelvic Exam. –vulva & thigh Pelvic Exam. –vulva & thigh excoriationsexcoriations

(ammoniacal dermatitis) (ammoniacal dermatitis)

Clinical Examination contd.Clinical Examination contd.

V/E –best performed in lateral position, V/E –best performed in lateral position, --may also be done in dorsal position. may also be done in dorsal position.

-digital to precede speculum exam.-digital to precede speculum exam.

-insert speculum of appropriate size-insert speculum of appropriate size

-visualize ant. Vaginal wall & then -visualize ant. Vaginal wall & then

-post. Vaginal wall-post. Vaginal wall

-Do digital rectal exam. to R\O RVF-Do digital rectal exam. to R\O RVF

EXAMINATION UNDER EXAMINATION UNDER ANAESTHESIA + DYE TESTSANAESTHESIA + DYE TESTS

Digital vaginal examination and examination Digital vaginal examination and examination with a Sim’s speculum may not confirm or with a Sim’s speculum may not confirm or exclude a fistula, thus necessitating exclude a fistula, thus necessitating examination under anaesthesia + DYE examination under anaesthesia + DYE TESTSTESTS A malleable silver probe is passed through A malleable silver probe is passed through openings in the vaginal wall;openings in the vaginal wall;

-For VVF and UVF, a metallic click against a -For VVF and UVF, a metallic click against a silver catheter may be felt or seen via a silver catheter may be felt or seen via a cystoscope.cystoscope.

-For RVF , the probe may be felt digitally in the -For RVF , the probe may be felt digitally in the rectum or seen via a proctoscoperectum or seen via a proctoscope..

EUA + DYE TEST Continued.EUA + DYE TEST Continued.

Enables assessment of available access Enables assessment of available access and the mobility of tissues for vaginal and the mobility of tissues for vaginal repair.repair.

The decision to repair vaginally or an The decision to repair vaginally or an abdominal approach can also be taken abdominal approach can also be taken then.then.

SPECIFIC INVESTIGATIONSSPECIFIC INVESTIGATIONS

DYES STUDIESDYES STUDIES

Investigations of first choiceInvestigations of first choice

Confirm if discharge is urinaryConfirm if discharge is urinary

If leakage is extra-urethral rather than urethralIf leakage is extra-urethral rather than urethral

To establish the exact site of leakageTo establish the exact site of leakage

Phenazopyridine -200mg tds orallyPhenazopyridine -200mg tds orally

Indigo carmine -intraveneouslyIndigo carmine -intraveneously

Methylene blue instillationMethylene blue instillation

DYE STUDIES contd.DYE STUDIES contd.

Patient in lithotomy positionPatient in lithotomy positionExamination best done under direct visionExamination best done under direct vision‘‘Three Swab Test’ has limitations and is Three Swab Test’ has limitations and is not recommended.not recommended.Adequate distension of the urinary bladderAdequate distension of the urinary bladderIf clear fluid leaks after instillation of dye, If clear fluid leaks after instillation of dye, ureteric fistula is likely.ureteric fistula is likely.Differentiate by “two dye test”Differentiate by “two dye test”Phenazopyridine to stain renal urine andPhenazopyridine to stain renal urine andMethylene blue to stain the bladder urineMethylene blue to stain the bladder urine

OTHER SPECIFIC OTHER SPECIFIC INVESTIGATIONSINVESTIGATIONS

Cystoscopy – small vvfCystoscopy – small vvfCystography – vesico uterine fistulae (lat. view) Cystography – vesico uterine fistulae (lat. view) Hysteroscopy/Hysteosalpingography-vesico Hysteroscopy/Hysteosalpingography-vesico

uterine fistulae ( lat. view)uterine fistulae ( lat. view)

Fistulography –small intestinal fistulaeFistulography –small intestinal fistulaeColpography –small fistulae involving vaginaColpography –small fistulae involving vagina

Endoanal Ultrasound, MRI –anorectal & Endoanal Ultrasound, MRI –anorectal & perineal fistulaeperineal fistulae

Barium enema, Barium meal & follow through Barium enema, Barium meal & follow through -Intestinal fistulae above the -Intestinal fistulae above the anorectum anorectum

GENERAL INVESTIGATIONSGENERAL INVESTIGATIONS

FBC + Blood film + Malaria Parasite FBC + Blood film + Malaria Parasite

Urine for urinalysis & m.c.s.Urine for urinalysis & m.c.s.

Stool for Parasitic InfestationsStool for Parasitic Infestations

CXRCXR

Serum E/U/CrSerum E/U/Cr

Intravenous UrographyIntravenous Urography

PREOPERATIVE PREOPERATIVE TREATMENTTREATMENT

Timing of definitive repairTiming of definitive repairImprove Patient’s General Health; high protein Improve Patient’s General Health; high protein diet, antimalarials, antihelmintics, haematinics & diet, antimalarials, antihelmintics, haematinics & Rx inter current infections/ diseasesRx inter current infections/ diseasesRx vulval dermatitis with silicone barrier Rx vulval dermatitis with silicone barrier creams, zinc oxide cream & castor oilcreams, zinc oxide cream & castor oil Bowel PreparationBowel PreparationProphylactic Antibiotics/ Urinary Antiseptics Prophylactic Antibiotics/ Urinary Antiseptics

REPAIR OF VVFREPAIR OF VVF

Route of Repair; vaginal or abdominalRoute of Repair; vaginal or abdominal

Position of Patient; lithotomy or reverse Position of Patient; lithotomy or reverse lithotomy (knee-elbow position)lithotomy (knee-elbow position)

Type of suture materials; absorbable -Type of suture materials; absorbable -vicryl 2/0 or chromic catgut 2/0vicryl 2/0 or chromic catgut 2/0

Types of Repair;(1) Dissection & repair in Types of Repair;(1) Dissection & repair in layers (2) layers (2)

SaucerizationSaucerization

POST OPERATIVE POST OPERATIVE MANAGEMENTMANAGEMENT

Fluid Balance; intake 3-4 litres per dayFluid Balance; intake 3-4 litres per dayoutput 120-150mls/hroutput 120-150mls/hr

Bladder Drainage; check drainage & vol. of Bladder Drainage; check drainage & vol. of urine hourlyurine hourly

Post Operative antibioticsPost Operative antibioticsPrevention of Deep Vein ThrombosisPrevention of Deep Vein ThrombosisCare of the perineum with vulva padsCare of the perineum with vulva padsDuration of Drainage; 10-14 days on the averageDuration of Drainage; 10-14 days on the averageRetraining of urinary bladder before discharge Retraining of urinary bladder before discharge

Post Operative Mgt. Contd.Post Operative Mgt. Contd.

Instructions on DischargeInstructions on Discharge

Repeat EUA & dye test on day 21 before Repeat EUA & dye test on day 21 before dischargedischarge

Refrain from sexual intercourse for 3monthsRefrain from sexual intercourse for 3months

Counsel for antenatal care & hospital Counsel for antenatal care & hospital delivery in all subsequent pregnanciesdelivery in all subsequent pregnancies

Elective Caesarean Section next pregnancy Elective Caesarean Section next pregnancy