Genital tract fistula

Genital tract fistula

1. Dr.Seetesh Ghose Professor & Head MGMCRI Genital Tract Fistula

2. What student should Learn At the end of this session student should be able To classify the genitourinary fistula To elicit the causes of genitourinary fistula To explain the presenting feature of genitourinary fistula To outline the investigations and management of genitourinary fistula. To list the steps to prevent genitourinary fistula

3. Definition Abnormal communication between the urinary and genital tract either acquired or congenital with involuntary escape of urine into vagina.

4. Types of Fistula Bladder Vesicovaginal Vesicourthrovaginal Vesicouterine Vesicocervical Urethra Urethrovaginal Ureter Ureterovaginal Ureterouterine Ureterocervical Rectum Rectovaginal

5. Simple Complex Size-2-3 cm Supra-trigonal(near cuff) No h/o radiation or pelvic malignancy Normal vaginal length Healthy tissue Good access Size > 3cm Involve trigon or distant from cuff H/O radiation or pelvic malignancy Shortened vaginal length Scarring tissue present Associated with ureter,rectum Types cont …..

6. Types cont ….. Depending upon the site of fistula Juxtacervical Midvaginal Juxtaurethral Subsymphysial

7. What leads to fistula Obstetrics cause Ischemic Obstructed labour Traumatic Instrumental vaginal delivery Destructive operation Hysterectomy

8. Gynecological cause Operative injury: Colporrhaphy , Hysterectomy Traumatic: Fall on sharp object , Fracture of pelvic bone , Stick used for criminal abortion Malignancy: Cervix , Vagina , Bladder. Infection : GTB , LGV, Schistosomiasis, Actinomycosis . Radiation

9. Symptoms & Signs Continuous escape of urine per vagina Gets urge but urine dribbles out into the vagina Secondary ammenorrhoea Foot drop Vulval inspection Ammoniacal smell Evidences of sodden and excoriation of the vulval skin Complete perineal tear or RVF

10. Internal examination Speculum examination Position Size Big- prolapse of Bladder mucosa Small- Puckered area on the vagina Tissue at the margin

11. Differential Diagnosis Stress incontinence Vesicovaginal Vesicourthrovaginal Ureterovaginal

12. Three swab test

13. Investigations Dye test To detect Three swab test To differentiate from ureterovaginal and urethrovaginal Intravenous Urography Ureterovaginal fistula Retrograde pyelography Exact site of ureterovaginal fistula Cystography Not routine. Vesico uterine Sinography ( Fistulography ) Intestinogenitalfistula Hysterosalpingography Vesico uterine USG, CT, MRI Complex fistula Cystourethroscopy Location of fistula in relation to ureteric orifice Examination under anaesthesia Identification of small fistula

14. Principles in the management (VVF) Detected during operation Immediate repair in two layer Detected in the postoperative period Indwelling catheter for 10 to 14 days If fails repair after 3 months Malignant or post radiation fistula Ileal bladder Anterior exenteration Colpocleisis Infective fistula Eradication of specific infection followed by local repair

15. Surgeries Saucerization (Pairing & Suturing) Latzko technique Martius graft

16. Principle of ureteric repair Not to damage ureteric sheath and its blood supply Ureteric mobilization and tension free anastomosis Watertight closure Stent with ureteric catheter Passive drain at the anastomotic site to prevent urine granuloma

17. Principle of ureteric repair During operation Urethral sheath denudation No intervention Ureteral stenting (Double J, Pig tail) Ureteral kinking Immediate removal of suture Ureteral ligation Immediate deligation Ureteral stenting if required Ureteral crushing Stenting & extraperitoneal drainage

18. Principle of ureteric repair Ureteral transaction Partial Primary repair over ureteric stent Complete Middle 1/3 rd –end-to-end anastomosis Lower 1/3 rd – ureteroneocystostomy with Psoas hitch Thermal injury Resection & implantation Bladder flap

19. Prevention Obstetrics fistula Adequate ANC Use of partogram Continuous bladder drainage for 5-7 days Ureteric fistula IVU Placing ureteral catheter Direct visualization / palpation Uriglow Adequate care to avoid injury during operative procedure

20. What you must remember Most common fistula Developing countries VVF -- Obstetric Developed countries Uretericvaginal fistula -- Trauma Identification of high risk cases Utmost care during any pelvic procedure If detected during procedure Immediate repair Proper drainage If detected following procedure Drainage for 10 to 14 days If fails – repair after 3 months

21. References Shaw ’s T ext books of Gynaecology - 16 th edition D C Dutta’s Text books of Gynaecology - 6 th edtion Thank you