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1. Genital Tract Fistula Presented by Mostafa Mashail Ahmed hamdy

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

3. Types of Fistula Bladder Vesicovnginal Vesicourthrovaginal Vesicoutefine VesicocervicaJ Urethra Urethrovaginal Ureter Ureterovaginal Ureterouterine Ureterocervical . Rectum Rectovaginal

4. Size— a — 3 CII1 Supra-trigonal(near cuff) No h/o radiation or pelvic malignancy Normal vaginal length Healthy tissue Good access Size > 3 cm Involve trigon or distant H/O radiation or pelvic malignancy Shortened vaginal length Scarring tissue present Associated with ureter,rectum Types cont.....

5. Types cont..... Depending upon the site of fistula

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

7. Gynecological cause Operative i iury: Colporrhaphy, Hysterectomy Traumatic: Fall on sharp object , Fracture of pelvic bone, Stick used for criminal abortion Malignant: Cervix , Vagina , Bladder. In f ection : GTB , LGV, Schistosomiasis, Actinoinycosis.

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

9. Internal examination Big- prolapse of Bladder mucosa Small- Puckered area on the vagina

10. Differential Diagnosis Stress incontinence Vesicovaginal Vesicourthrovaginal Ureterovaginal

11. Three swab test Result of 3 swab test Discolouration of topmost or middle swab vesicovaginal fistula Uppermost swab wetting but not discolouration W U reterovaginal fistula Discolouration of lower most swab but upper two swabs remain dry W U rethrovaginal fistula

12. Three swab test Intravenous Urography Retrograde pyelography Cystograpliy Sinography (Fistulography) Hysterosalpingography USG, CT, MRI CystDurethroscopy Examination under anaesthesia Investigations To differentiate from ureterovaginal and urethrovaginal Uirterovaginal fistula Exact site of ureterovaginal fistula Not routine. Vesicouterine Intestinogenitalfistula Vesicouterine Complex fistula Location of fistula iii relatiDn to ureteric orifice Identification of small fistula

13. Principles in the management (VVF) Detected during operation Imrne‹tiate i epaii i:z two 1ayei Detected in the postoperative period I ndivelling catheter foi io t 1 4 N VQS If fails i'epaii after 3 months Malignant or post radiation fistula Ileal bladder Anterior exenteration Colpocleisis Infective fistula Eradication of specific infection followed by local repair

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

15. 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

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

17. Principle of ureteric repair Ureteral transaction Partial Primary repa ir over ureteric stent Complete Middle i /3" — end- to- end anastomosis m /3“ — ureteroneocystostomy with Psoas hitfâi Thermal injury Resection & implantation Bladder flap

18. What you must remember Most common fistula Developing corn ti ice VVF -- Obstetric Uretencvaginal fistula — Trauma Identification of high risk cases Utmost care during any pelvic procedure If detected during procedure If detected following procedure If fails — repair after 3 months

19. References Shaw ’s Text books of Gynaecology- i6 t h edition D C Dutta's Text books of Gynaecology- 6 t h edtion