1. Lower Urinary Tract Fistulas
Jianhong zhou

2. HISTORIC PERSPECTIVES
Earliest evidence of a vesicovaginal fistula was reported in the mummified remains by Derry (1935)
Noted a large vesicovaginal fistula
Concluded that the presence of a severely contracted obstructed labor

3. HISTORIC PERSPECTIVES
Zacharin (1988) states that de Mercado first used the term fistula instead of the usual term rupture.
The discovery of antibiotics and the development of general and regional anesthesia contributed significantly to the surgical treatment of vesicovaginal fistulas in the twentieth century.

4. EPIDEMIOLOGY AND ETIOLOGY
Obstetric Fistulas
Obstructed labor
follow cesarean delivery of peripartum hysterectomy ,hemorrhage, and surgical inexperience
Gynecologic Fistulas
total abdominal hysterectomy—80%
urologists and colorectal, vascular, and general surgeons—20%

5. PRESENTATION AND INVESTIGATION
Gross hematuria or abnormal intraperitoneal fluid accumulation noted during or after surgery
urinary incontinence or persistent vaginal discharge presenting 7 to 21 days after surgery
unexplained fever; hematuria; recurrent cystitis or pyelonephritis; vaginal, suprapubic, of flank pain; and abnormal urinary stream

6. PRESENTATION AND INVESTIGATION
Complete physical examination
speculum examination of the vagina
Urine should be examined microscopically and cultured
Further office evaluation
cystourethroscopy
intravenous urogram permit the physician to localize the fistula
Office testing-- distinguish between fistulas involving the bladder or ureters
Instillation of methylene blue or sterile milk into the bladder stains vaginal swabs

7. CONSERVATIVE MANAGEMENT
Various conservative or minimally invasive therapies are available for vesicovaginal and ureterovaginal fistulas
Ureterovaginal fistula is confirmed, recommended initial management is ureteral stenting

8. TIMING OF SURGICAL REPAIR
early repair of vesicovaginal fistulas requires diagnosis of the fistula within 72 hours of the injury.
Once infection and indurations have occurred, a 3-to 6-month waiting period

9. PRESURGICAL MANAGEMENT
patients waiting surgical repair need considerable psychological support
use of tampons, perineal pads
Perineal care
vaginal or oral estrogen
In malnourished patients
not be performed during menstruation

10. SURGICAL REPAIR
Vaginal Repair of Vesicovaginal Fistula