1. GENITO-URINARY FISTULAS
Yashar Najiaghdam M.D

2. Definition Abnormal communications between urinary & genital organs.
Remember 2 golden rules
1st rule: urine may escape from
ureter  tube, uterus, cervix, vagina
bladder  tube, uterus, cervix, vagina
urethra  always vaginal.
2nd rule in naming a fistula,
Part of the urinary tract is 1st to be described

4. Varieties Vesico-vaginal Uretero-vaginal Urethro-vaginal
Vesico-cervical
Uretero-cervical
Uretero-uterine

5. VESICOVAGINAL FISTULA (The Commonest)

6. Aetiology Congenital: very rare. Traumatic fistula Obstetric trauma
Necrotic obstetric fistula
Traumatic obstetric fistula
Surgical trauma
Direct trauma
Inflammatory disease
Malignant neoplasms
Radium necrosis

7. Necrotic Obstetric Fistula
Prolonged compression of soft tissues between head & brim of a narrow pelvis.
→ ischaemia, pressure necrosis & sloughing of base of the bladder.
Urethra is also often involved.
Slough takes some days to separate
→ Incontinence develops 5-7 days after labour
Such fistulae are often surrounded by dense fibrosis

8. Traumatic Obstetric Fistula
Direct injury to bladder wall by sharp instrument (perforator or decapitation hook) during a difficult labour
Forceps rarely cause it
Incontinence Appears immediately After Labour

9. Traumatic Fistula Surgical trauma: Bladder may be injured
during vaginal operation as anterior colporrhaphy
during abdominal operations as hysterectomy.
Direct trauma: is a rare cause, but cases have occurred as a result of impalement.

10. Other Causes Inflammatory disease: result from Malignant neoplasms:
Bilharziasis of bladder
Tuberculosis of bladder.
A pelvic abscess may open into bladder & vagina
Malignant neoplasms:
As advanced carcinoma of cervix or of bladder, or vagina
By direct invasion of the wall and ulceration.
Radium necrosis:
Sloughing of the bladder
As a complication of radium treatment used for cure of malignant disease in pelvis

11. Symptoms Incontinence of urine Symptoms of vulvitis: Cystitis
Complete (large fistula) OR
Partial (small or high fistula)
DD: uretero-vaginal fistula.
Symptoms of vulvitis:
Pruritus, burning pain due to continuous discharge of urine.
Cystitis
Due to ascending infection from vulva

12. Diagnosis History of incontinence following labour or operation.
Several days after labour  necrotic obstetric fistula
Immediately after difficult labour  traumatic fistula.
Palpation of anterior vaginal wall:
Large fistula Can be felt
Small fistulas cannot be felt, but surrounding fibrosis is usually palpable

13. Diagnosis Inspection of the anterior vaginal wall
In Sims’ position or left lateral (semi-prone) position
With the use of Sims’ speculum.

14. Diagnosis For small and high fistula
Dye test: Injection of methylene blue into bladder by a catheter to outline the fistula while anterior vaginal wall is inspected by use of Sim’s speculum.
DD: uretrovaginal fistula
Sometimes a metal catheter or sound is passed through the urethra to appear at the fistulous opening.

15. Management Prophylaxis: Antenatal: During labour
Diagnosis of abnormalities that possibly result in fistula formation
contracted pelvis
malpresentations
During labour
Diagnose and deal with:
prolonged labour
Malpresentations
Risky operations should all be avoided
high forceps
forceps with incompletely dilated cervix
risky destructive operations.

16. Management
If injury to the bladder is discovered during a difficult labour,
Don’t suture the tear due to tissue oedema and friability.
fix rubber catheter for 10 days
The tear may heal completely or be much smaller
If the injury is detected some time after labour, as in cases of necrotic fistulas,
operations done except at least 3 months after delivery to allow for maximum involution of the tissues.

17. Preoperative Preparation
Treat vulvitis:
Cover skin of the vulva, and inner thighs by a thick layer of Vaseline, zinc oxide ointment or any bland ointment, to prevent maceration of the skin by the continuous discharge of urine.
Renal function tests:
Culture of urine,
if pathogenic organisms are found, patient is given urinary antiseptics until urine is sterile.

18. Methylene blue test
to differentiate a small vesico-vaginal fistula from a uretero-vaginal fistula.
3 pieces of gauze are placed in the vagina
200 cc of sterile fluid coloured with methylene blue is Injected into the bladder
The lowest piece of gauze is discarded as it is usually stained during filling the bladder.
If the middle or upper pieces stain → fistula is vesical
If none of the pieces stain and the upper one is wet with uncoloured urine → fistula is ureteric.
If all are dry and unstained → excludes vesical or ureteric fistula.

19. Methylene
blue
test

20. Cystoscopy
Determine relation of the fistula to ureteric openings in bladder
Exclude multiple fistulas
Reveal associated bladder pathology.
Chromocystoscopy
IV Injection of 4 c.c. of 0.4% indigocarmine solution
If kidney function is good → Blue efflux from the ureter in 4 minutes.

21. Operation flap-splitting operation, or dedoublement
Circular incision around the fistula.
The 2 short longitudinal cuts upwards and downwards
Through the thickness or the vagina but not the bladder.
→ 2 flaps of vaginal wall.
Free mobilization of the vaginal flaps from the bladder over a wide area, at least 1.5 cms around the fistula.
Circular
incision
Long.
Fistula

22. Operation
The hole in bladder is then closed by 2 layers of interrupted sutures going through muscle wall only & not piercing the mucous membrane.
The vagina is then closed by interrupted sutures going through its whole thickness.
A rubber catheter is fixed in the urethra
Tight vaginal pack to prevent reactionary haemorrhage.

24. The saucerisation operation (Sim’s operation)
Indicated
If tissues are too adherent and fibrosed to do flap splitting
After failure of the flap splitting.
Technique:
Edge of the fistula is excised removing a wider part of the vagina than of the muscle wall of the bladder
Edges of both organs are simultaneously coapted together by the use of nonabsorbable sutures
Certain high fistulae are better treated by abdominal (transperitoneal or transvesical) repair.

25. Postoperative Care Recumbent position
The bladder should be constantly empty.
Fluids (3 litres/day).
Urinary antiseptics & antibiotics.
Vaginal pack is removed 24 hours after operation.
Catheter is removed after 10 days.
After its removal the patient is instructed to void urine
every two hours by day &
every four hours by night,
to avoid over-distension of bladder & disruption of suture line.

26. Subsequent Management
Patient is instructed to
avoid sexual intercourse for 3 months
avoid pregnancy for 1 year
Caesarean section is almost absolutely indicated.

27. URETERO-VAGINAL FISTULA
Cause:
Injury to ureter during a gynaecological operation as hysterectomy
may develop following a difficult labour.
It leads to incomplete incontinence
Urine from affected ureter escapes from vagina while bladder fills up & empties normally from other ureter
It is always small & high up in vagina lateral to cervix.
Differentiated from a vesico-vaginal fistula by:
by methylene blue test.
Cystoscopy shows ureteric efflux on one side only.

28. Prophylaxis Ureteric injury can be avoided by
pre-operative intravenous pyelography
ureteric catheterization
proper surgical technique.

29. Treatment Abdominal re-implantation of ureter into bladder.
If not possible, ureter is transplanted into sigmoid colon.
If kidney function is very poor on the affected side → kidney can be sacrificed.

30. Kidney Function Tests Blood urea: Normally 20-40 mg%.
Specific gravity of urine before and after water administration (water concentration test):
Normally high before, low after
In chronic nephritis → low fixed S.G. of about 1010.
Urea concentration test: Normally urea in urine' should be 2% or over after administration of 15 grams of urea by mouth.
Urea clearance test: It is a delicate test.
It indicates the no. of cm3 of blood cleared of urea per minute
Average = %
< 50% → renal impairment.
Intravenous pyelography.

31. Types Of Incontinence Of Urine
True incontinence  genito-urinary fistula.
Stress (Sphincter) incontinence  weakness of Internal urethral sphincter.
Urgency incontinence  severe inflammation leading to marked irritation of bladder & so urge to pass urine cannot be inhibited & some urine will pass involuntary while patient is in her way to W.C.
False incontinence  retention with overflow
Nocturnal enuresis.

32. Causes Of Retention Of Urine
Cause of urinary retention is an impacted pelvic mass.
Diagnosis is made clear by attention to associated symptoms

33. Associated Conditions
Diagnosis
Primary amenorrhea
→ Haematocolpos
Secondary amenorrhea
→  Retroverted gravid uterus
Menorrhagia
→ Uterine fibroid
No menstrual upset
→ Ovarian or broad ligament tumour
Irregular bleeding
→ (1) threatened abortion from a retroverted gravid uterus,
→ (2) pelvic haematocele
→ (3) pelvic abscess 
Labour
→ Descent of the foetus to from a pelvic tumour