GENITO-URINARY FISTULA.pptx

Genito urinary fistula

1. GENITO-URINARY FISTULA

2. Fistula – abnormal communication b/w two or more epithelial surfaces. Genitourinary fistula – abn communication b/w urinary & genital tract either acquired or congenital with involuntary escape of urine into the vagina. Incidence – 0.5 – 3% among gynae admissions

3. Types: The communication may occur b/w Bladder Urethera Genital tract Ureter Bladder Vesicovaginal (commonest) Vesicourethrovaginal Vesicouterine vesicocervical

4. Urethera Urethrovaginal Ureter Ureterovaginal Ureterouterine ureterocervical

5. Vesicovaginal fistula: Communication b/w bladder & vagina and urine escapes into the vagina causing true incontinence. This is the commonest type of genitourinary fistula Causes : Obstetrical Gynaecological

6. Cause of obstetric fistula Obstructed labour Forceps delivery Cesarean Destructive surgeries symphysiotomy

7. Unrelieved Obstructed Labour Prolonged pressure of the babies head crushes the base of the bladder against the pubic bone

8. The devitalized area separates as a slough, usually between the 3 rd and 10 th day of the puerperium, with resulting fistula formation and incontinence.

9. Gynaecological : Operative injury: I n surgeries like Ant.colporrhaphy , Abdominal Hysterectomy Traumatic: fall on pointed object; #pelvic bones; retained & forgotten pessary

10. Malignancy: Ca cervix , vagina & bladder Radiation: ischemic necrosis (Ca Cervix treated by radiation) Infective: vaginal TB, LGV

11. Types: Simple: healthy tissue with good access Complicated: tissue loss; scarring; difficult access; associated with RVF

12. Depending upon site of fistula Juxtacervical (close to the cervix): supratrigonal region of bladder = vagina Midvaginal : base( Triogone ) of bladder = vagina Juxtauretheral : neck of bladder = vagina

13. Clinical features: Patient profile – young primiparous with H/O difficult labour or instrumental del. Symptoms: - continous escape of urine per vaginum is the classical symptom - patient has no urge to pass urine - if fistula small, escape of urine occurs in certain position, pt can pass urine normally - pruritus vulvae

14. Signs: - escape of watery discharge per vaginum of ammoniacal smell - excoriation of vulval skin Internal exam: - if fistula is big enough its position, size and tissues at the margins are to be noted

15. Diagnosis: History Local examination Investigations Urinalysis and urine culture Intravenous urography Dye Test Cystourethroscopy

16. The four cardinal principles of investigation are (1) confirm that the discharge is urinary; (2) confirm that leakage is extra-urethral; (3)identify site of leakage; and (4) identify or exclude multiple or complex fistulous tracks.

17. Dye Test Identification of the site of a fistula is best carried out by the instillation of coloured dye (usually methylene blue) into the bladder, with the patient in the lithotomy position and any leakage directly visualised.

18. 3 swab test (Moir)- 3 large pledgets of cotton wool placed in the vagina, one above the another Methylene blue solution run into the bladder If only the lowest swab stains-fistula is urethral Middle or upper swab stains-fistula is vesical None of the swabs stain but upper one is wet-fistula is ureteric

19. Investigations: Intravenous urography - for diagnosis of ureterovaginal fistula Cystoscopy - exact level and location of fistula and its relationship to ureteric orifices and bladder neck

20. Treatment: Preventive: - adequate antenatal care to screen out ‘at risk’ mothers likely to develop obstructed labour - partographic management and monitoring of labour - catheterisation for 5-7 days in postnatal period in a case of long standing obstructed labour - avoid injury to bladder during pelvic surgery

21. Immediate management: - continous catheterisation for 6-8 weeks - helps spontaneous closure of fistula tract - unobstructed outflow tract helps epithelialisation , provided tissue damage is minimum

22. Operative: Local repair of fistula is the surgery of choice - preoperative assessment - preoperative preparation - definitive surgery

23. Preoperative assessment: Fistula status – site; size; no.; mobility and status of margins of the fistula Uretheral involvement is assessed by introducing metal catheter through ext uretheral meatus into bladder To ascertain position of ureteric openings in relation to big fistula. To exclude associated RVF or CPT CHG, RFT are done

24. Preoperative preparation: Improvement of general condition of pt. Local infection treated UTI should be treated

25. Definitive surgery(old obstetric VVF): Ideal time of surgery is after 3 months following delivery Surgical fistula if recognised within 24hrs, immediate repair may be done provided small

26. Local repair by flap splitting method: Principals of surgery: Perfect asepsis and good exposure of fistula Excision of scar tissue round the margins Mobilisation of bladder wall from vagina Suturing the bladder wall without tension in two layers Apposition of the vaginal walls by interrupted sutures To maintain continous bladder drainage by indwelling catheter.

27. Latzko technique: Vaginal mucosa dissected off bladder wall around fistula site Fistula tract is excised Bladder mucosal edges are approximated Two additional suture layers are used to appose the muscle and fascia Vaginal mucosa closed by interrupted sutures Bladder drainaige (catheter) for 10-14 days

28. Special postop care: Urinary antiseptics Catheterisation for 10-14 days Pt advised to pass urine frequently (2hrly) following removal of catheter. Interval is gradually increased

29. Criteria for successful repair: CRITERIA GOOD PROGNOSIS UNCERTAIN PROGNOSIS No. of Fitula single Multiple Site VVF RVF Mixed (RVF & VVF) Size < 4cm > 4cm Uretheral Involvement Absent Present Vaginal Scarring Absent Present Tissue loss Minimal Extensive Ureter involvement Ureters draining inside bladder Ureters draining into vagina

30. Advice during discharge: To pass urine more frequently To avoid intercourse for 3 mth Defer pregnancy for 1 yr If conceives – mandatory antenatal checkup & hospital delivery - a successful repair should have an abdominal delivery if repair fails – local repair again attempted after 3 months

31. Other routes of repair of bladder fistula: Transperitoneal – Vesicouterine fistula Transvesical – fistula unapproachable per vaginum Transperitoneal or transvesical approach is preferred when the fistula margins are close to the ureteral orifices

32. Principles in the management of gynaecological VVF: Detected during operation : to repair immediately in two layers Detected in postoperative period : catheterise for 10-14 days, if fails repair after 3 months Malignant or postradiation fistula: - Ileal bladder ; ant. Exenteration ; Colpoclesis Infective fistula : eradication of specific infection f/b local repair

33. Urethrovaginal fistula: Causes: - same as VVF - Injury during ant. Colporrhaphy , uretheroplasty , suspension or sling operation for stress incontenence - residual fistula left after vesicourethrovaginal fistula

34. Diagnosis: Pt has urge to pass urine but urine dribbles out into vagina during the act of micturition Metal catheter passed through ext uretheral meatuscomes out through uretherovaginal opening In case of confusion with VVF or UVF, three swab test may be employed

35. Treatment: Surgical repair in two layers f/b continous bladder drainage as in VVF repair.