Fistula and various types in obstetrics and gynecological nursingpptx

Obstetrics and gynecological nursing

1. FISTULAE

2. GENITOURINARY FISTULA Definition Genitourinary fistula is an abnormal communication between the urinary and genital tract either acquired or congenital with involuntary escape of urine into the vagina.

3. Types The communication may occur between the bladder, urethra or ureter and genital tract. Bladder Vesico vaginal (most common) Vesico urethrovaginal Vesico uterine Vesico cervical

4. Types ureter Uretero vaginal Uretero uterine Uretero cervical.

5. Vesicovaginal Fistula Definition There is communication between the bladder and the vagina, and urine escapes into the vagina causing true incontinence.

6. Causes 1.Obstetrical : The most common cause is obstetrical. The fistula may occur due to ischemia or following trauma: Ischemic : The fistula results from prolonged compression effect on the bladder base between the fetal head and symphysis pubis in obstructed labor. Prolonged labour

7. Causes Traumatic: This may be caused by: -Instrumental vaginal delivery such as destructive operations or forceps, -Abdominal operations such as hysterectomy for rupture uterus . traumatic fistula usually follows soon after delivery.

8. 2 . Gynecological : The common gynecological cases are: Operative injury : During operations like anterior colporrhaphy , abdominal hysterectomy or removal of Gartner's cyst Traumatic : Injury to anterior vaginal wall and the bladder wall following fall on a pointed object, use of a stick for criminal abortion etc.

9. Malignancy: Advanced carcinoma of the cervix, vagina and bladder may produce fistula by direct spread. Radiation: Ischemic necrosis may occur when carcinoma cervix is treated by radiation in 1-2 years. Infective: Chronic granulomatous lesions such as vaginal tuberculosis, lymphogranuloma venereum and actinomycosis may produce fistula.

10. Clinical Features 1. Patient profile: The patients are usually young primiparous with history of difficult labor or instrumental delivery in recent past. 2. Continuous escape of urine per vagina is the classic symptom. The patient has no urge to pass urine. 3. Pruritus vulva.

11. Clinical Features 4. Escape of watery discharge per vagina of ammoniacal smell. 5. Symptoms of UTI 6. On speculum examination; the bladder mucosa may be seen prolapsed through a big fistula.

12. Diagnosis of Fistula 1.Examination under anesthesia (EUA). 2.Examination in Sims' or knee-chest position: Bubbles of air are seen through the tiny fistula when the woman coughs. 3.Dye test; A speculum is introduced and the anterior vaginal wall is swabbed dry. When the methylene blue solution is introduced into the bladder by a catheter, the dye will be seen coming out through the opening.

13. 4. Catheter test: A metal catheter passed through the external urethral meatus, when passes out through the fistula, VVF is confirmed. 5. Three swab test : Three cotton swabs are placed in the vagina, one at the vault, one at the middle and one just above the introitus . Methylene blue is instilled into the bladder through a rubber catheter and the patient is asked to walk about for 5 minutes. She is then asked to lie down and the swabs are removed for inspection.

14. Investigations 1.Intravenous urography: For the diagnosis of ureterovaginal fistula. 2.Retrograde pyelography: For the diagnosis of exact site of ureterovaginal fistula. 3.Cystography: In complex fistula or vesicouterine fistula where lateral view of uterine cavity may be seen. 4.Endoscopy studies to identify the exact location of the fistula and its relationship to ureteric orifices and bladder neck.

15. Treatment 1.Prevention : Obstetric fistula is prevented with safe motherhood initiative. The measures to be taken are : Adequate antenatal screening to identify at risk mothers likely to develop obstructed labor. Early detection and ideal approach in the method of delivery in relieving the obstruction.

16. Treatment Continuous bladder drainage for 5-7 days following delivery either vaginally or abdominally in a case of long-standing obstructed labor. Care to avoid injury to the bladder during pelvic or gynecological surgery.

17. 2. Immediate management : Once the diagnosis is made, catheterization and continuous bladder drainage for 6-8 weeks is maintained. - This may cause spontaneous closure of the fistula tract that is small, with minimal tissue damage.

18. 3.Operative management : Local repair of the fistula is the surgery of choice; The ideal time for surgery is after 3 months following delivery in case of old VVF. Surgical fistula recognized within 24 hours may be repaired immediately.

19. Postoperative Care Urinary antiseptic either at random or appropriate to the sensitivity report. Continuous bladder drainage for about 10-14 days. Advise to pass urine 2 hourly following removal of catheter. The interval to be increased gradually.

20. Instructions during Discharge from Hospital To pass urine more frequently To avoid intercourse for at least 3 months To differ pregnancy for at least 1 year If conception occurs to report to the physician and must have mandatory antenatal checkup and hospital delivery.

21. URETHROVAGINAL FISTULA

22. URETHROVAGINAL FISTULA The causes are the same as those of VVF. Part or whole of the urethra is involved along with the bladder. Small isolated urethrovaginal fistula is caused by: .Injury inflicted during anterior colporrhaphy , urethroplasty Residual fistula left behind following repair of vesicourethrovaginal fistula.

23. Diagnosis 1. The patient has urge to pass urine, but urine dribbles out into the vagina during the act of micturition. 2. A sound or a metal catheter passed through the external urethral meatus comes out through the communicating urethrovaginal opening. 3. 'Three swab test' may be employed to confirm the diagnosis.

24. . Treatment Surgical repair in two layers followed by continuous bladder drainage as outlined for VVF is done. Prior suprapubic or vaginal cystectomy ensures better success. In cases of complete destruction of the urethra, reconstruction of urethra is performed. Stress incontinence may occur in 10-15% of cases following repair.

25. URETEROVAGINAL FISTULA

26. URETEROVAGINAL FISTULA Causes 1. Congenital: The aberrant ureter may open into the vault of vagina, uterus or into urethra. 2. Acquired: This is the most common type and usually follows trauma during pelvic surgery.

27. Signs and symptoms are subtle and often overlooked. Patient may develop fever, flank pain, hematuria, abdominal distension, urine leakage through vagina, peritonitis .

28. Investigations 1. Three swab test. 2. Intravenous Indigo Carmine test: Indigo Carmine is injected intravenously. If urine in the vagina becomes blue in 4-5 minutes, the diagnosis of ureterovaginal fistula is established. 3. Cystoscopy: to determine the side 4. Excretory urography/intravenous urography (IVU)- confirms the side, site and tract of ureterovaginal fistula. 5. Renal ultrasound. 6. Computed tomography (CT).

29. Management When injury is recognized during operation: Ureteral sheath denudation: No intervention and rarely ureteral stenting. 2. Ureteral kinking : Immediate removal of suture. 3. Ureteral ligation: Immediate delegation-assessment of viability by blood flow and ureteral peristalsis.

30. Management 4. Extraperitoneal drainage. 5. Ureteric implantation into the bladder, if the length of ureter is sufficient. 6. Bladder flap procedure when the ureter is short or injury is at the level of pelvic brim.

31. RECTOVAGINAL FISTULA

32. RECTOVAGINAL FISTULA Definition Abnormal communication between the rectum and vagina with involuntary escape of flatus and/or feces into the vagina is called rectovaginal fistula.

33. RECTOVAGINAL FISTULA Acquired Obstetrical Incomplete healing or unrepaired recent complete perineal tear (CPT) Obstructed labor causing pressure necrosis ,Instrumental injury inflicted during destructive operation.

34. Gynecological Incomplete healing of repair of old CPT Trauma . Fall on sharp pointed object. Malignancy of the vagina, cervix or bowel. Radiation.

35. Gynecological Lymphogranuloma venereum or tuberculosis of vagina. Diverticulitis of the sigmoid colon. Crohn's disease involving the anal canal or lower rectum. Congenital The anal canal may open in to the vestibule or in to the vagina

36. Diagnosis Involuntary escape of flatus and/or feces into the vagina Rectovaginal examination reveals the size and site of fistula Dye test: Probe test: Passing a probe through the vagina into the rectum. Examination under anesthesia.

37. Investigations .Barium enema .Barium meal and follow through to confirm the site of intestinal fistula . Sigmoidoscopy and proctoscopy .

38. Treatment Preventive Good antenatal care Identification of complete perineal tear and effective repair Care to prevent injury during gynecologic surgeries.

39. Treatment Definitive Extension to CPT and repair . Repair by flap method for injury situated in the middle third •For defect situated high-up, preliminary colostomy for local repair after 3 weeks and closure of colostomy after 3 weeks

40. THANK YOU