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 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 induration have occurred, a 3-to 6-month waiting period

9. PRESURGICAL MANAGEMENT patients waiting surgical repair need considerable psychological support the 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