SlideShare una empresa de Scribd logo
1 de 78
GENITAL TRACT FISTULAS
Dr. Shaheen Hokabaj
C. S. I, Mysore
DEFINITIONDEFINITION
• A FISTULA is an abnormal communication
between two or more epithelial surfaces
• GENITAL TRACT FISTULA is an abnormal
communication between epithelial surfaces of
Urinary  Genital Tract
Intestine  Genital Tract
Skin  Genital Tract
GENITAL TRACT FISTULAS
CLASSIFICATION
I
II
III
I. GENITOURINARY
FISTULAS
II. INTESTINO-GENITAL
FISTULAS
III. GENITAL TRACT- SKIN
FISTULA
IV. URO-INTESTINO-
GENITAL (COMPOUND)
V. GENITAL TRACT FISTULA,
UNSPECIFIED
GENITOURINARY FISTULA
GENITOURINARY FISTULA
• Is an abnormal communication between
urinary and genital tract with involuntary
escape of urine into the genital tract
• 2-7 Million women affected worldwide
• 0.2-1% of gynecologic admission
TYPES
BLADDER URETER URETHRA
Vesicovaginal Ureterovaginal Urethrovaginal
Vesicouterine Ureterouterine
Vesicocervical Ureterocervical
Vesicourethro-
vaginal
1-vesicovaginal
2-vesicourethrovaginal
3-urethrovaginal
4-vesicocervical
5-ureterovaginal
6- vesicouterine
AETIOLOGY
GENITOURINARY FISTULA
ACQUIRED
OBSTETRICAL GYNAECOLOGICAL ACCIDENTAL
CONGENITAL
AETIOLOGY
• CONGENITAL MALFORMATION
– Aberrant ureter and persisting urogenital sinus
– Mostly associated with other urinary tract
abnormalities
• ACCIDENTS
– Road traffic accident  Crush injuries to the
pelvis  bone fragments can cause
perforation of the bladder or urethra
– Avulsion of urethra
– Fall on pointed object
• OBSTETRICAL CAUSES
In the developing countries- commonest cause
accounts for 80-90% of cases (developed 5-15%)
– ISCHEMIC NECROTIC OBSTETRIC FISTULA
Prolonged Obstructed labour
- CPD and malpresentation  trigone of bladder is
nipped between presenting part and pubic
symphysis  ischemic tissue necrosis 
sloughing genitourinary fistula
- Slough take some days to separate  thus
incontinence develops 7-10 days after delivery
Obstructed labor
Trigone of bladder is
nipped in between pubic
symphysis and presenting
Part
Compression ischemia
Necrosis
Fistula formation
7-10th postnatal day
Fetal death
Fistula formationFecal incontinence Urinary incontinence
Complex urological injury
Vaginal scarring and stenosis
Secondary infertility
Chronic skin irritation,
Offensive odours
Stigmatization
Isolation and loss of social support
Divorce or separation
Worsening poverty
Worsening malnutrition
Obstructed Labor Injury Complex
• OBSTETRICAL CAUSES
- TRAUMATIC FISTULA
– Instrumental Vaginal delivery such as destructive
operations or forceps specially with kielland.
• Injury inflicted by bony spicule of the fetal skull in craniotomy
operation
– In Caesarean section
• At risk in patient with previous LSCS
• if bladder is caught in the suture can cause ischemia leading
to fistula formation
- Ligation of main branch of uterine vessels in case of
hemorrhage due to lateral extension of transverse incision in
LSCS Ureters are at risk of injury
- Rupture of scar of previous LSCS can implicate adherent
bladder base
In such direct traumatic injury, fistula and incontinence
follows soon after delivery
• GYNAECOLOGICAL CAUSES
OPERATIVE INJURY
– In developed countries it accounts for 70% of fistulas
– In nearly all gynaecological operations one or other
part of the urinary tract is in danger
– URETER- is at risk in total hysterectomy especially
radical hysterectomy, removal of broad ligament
tumours
- Risk of ureteral injury was seven times greater with
laparoscopic procedures than with open procedures
- URETHRA- is threatened during anterior colporrhaphy
and sling operation
Post surgical fistula - Pathophysiology
Unrecognized bladder injury during difficult hysterectomy or cesarean
Or surgery involving anterior vaginal wall
Post hysterectomy fistula – located above the interureteric
ridge
Overvigorous blunt dissection
of bladder from the uterus
Result in tear in Post bladder wall or
devascularisation
Tissue ischemia, necrosis
Fistula
Vaginal cuff suture –
Incorporated into bladder
1. 2.
• MALIGNANCY-
– Advanced carcinoma of cervix, vagina or bladder  may
produce fistula by direct spread
• RADIOTHERAPY
– Excessive, misapplied and even well applied irradiation
for pelvic malignancy esp carcinoma of cervix causes
endarteritis obliterans ischaemic necrosis  fistula
– Late complication- takes 1-2 years to produce such fistula
• INFECTIVE
– Vaginal foreign bodies, forgotten and retained pessaries
– Chronic granulomatous lesions such as genital
tuberculosis, LGV, schistosomiasis, actinomycosis – rare
causes of fistula
VESICOVAGINAL FISTULA
(The Commonest)
VVF is an abnormal communication between bladder and vagina and the urine escapes into
the vagina resulting in true incontinence
HISTORICAL PERSPECTIVE
• The first record of a VVF is found in the writings of
ancient Hindu medicine, the Vedas and Upavedas.
• Avicenna, a Persian physician, was the first known
writer to mention the occurrence of a VVF and also
recognized the association between such a lesion and
labor
• James Marion Sims, 1852- Father of surgery of VVF first
published his method for the surgical treatment of VVF
using a transvaginal approach
• Trendelenburg in 1888 successfully performed the
transabdominal VVF repair.
Predisposing factors
• History of pelvic irradiation
• Cesarean section
• Endometriosis
• Prior pelvic surgery
• Pelvic inflammatory disease
• Diabetes mellitus
• Concurrent infection
• Vasculopathies
• Tobacco abuse
Classification of VVF
• Simple
- Fistula <2-3 cm in size
- Supratrigonal
(near the cuff)
- No history of radiation
or pelvic malignancy
- Vaginal length is
normal
- Healthy tissue
- Good access
• Complicated
- Fistula >3 cm in size
- Fistula distant from cuff or
has trigonal involved
- H/o previous radiotherapy
and Pelvic malignancy is
present
- Vaginal length is shortened
- Associated with scarring
- Involving urethra, vesical
neck, ureter, intestinal
fistula
- Previous unsuccessful
attempt at repairs
Classification according to the site of
fistula
I. High fistula
1. Juxtacervical 2. Vault (vesicouterine)
II. Mid Vaginal fistula
III. Low fistula
a. Bladder neck- Urethra intact
b. Urethral involvement- segmental(Partial bladder neck
loss
c. Complete bladder neck loss- circumferential fistula
IV. Urethrovaginal fistula
A small fistula below the bladder neck is incompetent
V. Massive vaginal fistula encompasses all three levels and
often includes one or both ureters in addition
Classification according to the size
• Small <2 cm
• Medium 2-3 cm
• Large 4-5 cm
• Extensive >6 cm
EVALUATION OF VVF
• History
• General and Genital Examination
• Confirmation of diagnosis
• Radiological Evaluation
• Cystoscopic Evaluation
HISTORY
• VVF is usually presented with continuous escape of urine
per vaginum ( true Incontinence)- CLASSIC SYMPTOM.
• Patient got no urge to void urine
• Small fistula- escape of urine occur in certain position and
can also pass urine normally
• Leakage of urine following surgical injury occurs from the
first postoperative day
• Obstetrical fistula- symptoms take 7-14 days to appear
• Urethral fistula situated high up- may present with stress
incontinence
• Vesicocervical and vesicouterine fistulae- may hold urine at
the level of uterine isthmus and remain continent
• Menouria- cyclical hematuria at the time of menstruation is
present
• Pruritis vulvae, perineal skin irritation, fungal infection due
to constant wetness
HISTORY
• Age and socioeconomic status of women
• Previous gynaecological surgery/radiotherapy
• Previous history of prolonged labour/ trauma
during childbirth
If previous delivery is suspected as cause  detailed
obstetric history should be gathered.
• Time of occurrence
• History of urine leakage
• Timing of leakage, amount of leakage
• Voiding per urethra apart from the leakage
• Any leakage of faeces, gas leakage
• Any attempt of previous repair of fistula
EXAMINATION
• General Examination
• Per Abdomen examination- surgical scars
• Vulval Inspection
– Escape of watery discharge per vaginam of
ammoniacal smell is characteristic
– Sodden and excoriation of the vulval skin
– Varying degree of perineal tears may be present
• Per Speculum Examination
– Sim’s position and Sim’s Speculum
– Any pooling of fluid in the vagina
– Site, size, number of fistula
– Assess quality of surrounding tissue; tissue mobility
– Bladder mucosa may be visibly prolapsed through a
big fistula
• Tiny fistula-
– is evidenced by a
puckered area of vaginal
mucosa
– when women coughs
while lying in sims
position bubbles are seen
coming through tiny
fistula
• Per Vaginal examination
– Palpate anterior and
posterior vaginal wall
– Gives better idea of fistula
– Assessment of tissue
mobility, size, site,
determination of the
degree of tissue
inflammation, edema and
infection
Sims position
Sims
speculum
CONFIRMATION OF DIAGNOSIS
• Dye test
Methylene blue introduced into bladder by a catheter  dye will
be seen coming through the opening
• Three Swab test /Tampon test of Moir
• Double dye test
Give patient oral phenazoyridine, fill the bladder with the blue
tinted solution and insert a tampon.
Presence of blue staining suggest- VVF or urethrovaginal fistula
Red staining (pyridium) suggest ureterovaginal fistula
• Metal catheter passed through external urethral meatus
into the bladder when comes out through the fistula in
vagina confirms VVF and patency of urethra
• Examination under anaesthesia
Midvaginal obstetric fistula- metal catheter is passed through it
3 swab test (Vaginal Gauze test)
• Three separate sponge swabs are placed into
the vagina one above the another
• The bladder is then filled with a coloured
agent such as methylene blue through a
rubber catheter, and patient asked to do some
exertional manuevers and then the swabs are
removed after 10 mins.
Result of 3 swab test
1. Discolouration of topmost
or middle swab 
vesicovaginal fistula
2. Uppermost swab wetting
but not discolouration
 Ureterovaginal fistula
3. Discolouration of lower most
swab but upper two swabs
remain dry
 Urethrovaginal fistula
1
2
3
Laboratory studies
• Vaginal vault fluid collection
– Tested for urea, creatinine and potassium
– To determine likelihood of diagnosis of VVF
– Rule out vaginitis
• Urine C/S
• Biopsy of fistula tract/ urine cytology if
suspicious of malignancy
Imaging studies
• Radiologic studies are recommended prior to surgical
repair of a vesicovaginal fistula to fully assess the
defect and exclude the presence of multiple fistulae
• Intravenous urography- for the diagnosis of
ureterovaginal fistula
• Retrograde pyelography- if IVP negative and high
suspicion of ureterovaginal fistula
• Cystography- done in complex fistula
• Sinography (fistulography)- for intestinogenital fistula
• HSG- for diagnosis of vesicouterine fistula when patient
presents with symptoms of menouria
• Ultrasound, CT,MRI- done for evaluation of complex
fistulae
Diagnostic procedures for VVF
• Cystoscopic Examination
• Cystoscopic Examination using CO2 gas (FLAT TIRE
sign)
• Combined Vaginoscopy- cystoscopy
– Transillumination of the bladder or vagina by turning
off the vaginal or bladder light allows for easier
identification in difficult cases
• Colour Doppler ultrasonography with contrast
media of the urinary bladder in cases where
cystoscopic evaluation is equivocal
• Fistulograms- indicated if conservative therapy is
planned.
Cystogram showing extravasation of dye
from bladder into vaginal canal
Cystoscopic view of fistula
PREVENTION
OBSTETRIC FISTULA
• PRIMORDIAL PREVENTION
– Girl’s Education
– Women’s Empowerment
– Increase the age of marriage
– Nutritious diet since childhood
• PRIMARY PREVENTION
– Availability of family planning method services
– Strategy to make motherhood safer should be followed
– Good antenatal care
– Watchful progress of labour
– Trained birth attendants
– Transportation and emergency obstetric care
PREVENTION
• SECONDARY PREVENTION
– Early recognition of CPD and prevention of obstructed
labour
– LSCS in indicated cases
– Avoidance of difficult forceps and destructive
operations
– Prolonged Catheter drainage in prolonged or
obstructed labour.
RADIATION FISTULA
• Proper dose and technique of irradiation
• Packing of the vagina
• Midline block
If you suspect fistula is going to form following
obstructed labour or destructive operation
– Insert an in dwelling catheter and start continuous
closed drainage
– Ensure a high fluid intake
– Mobilize her early, always keeping the bag below
her bladder
– After 7-10 days examine her anterior vaginal wall in
Sim’s position with speculum
• If her bladder is still bruised or necrotic
– Leave her catheter in and remove only when
healthy tissue is seen in next examination
PREVENTION
SURGICAL FISTULA
• Adequate exposure during surgery
• Minimize bleeding and hematoma
formation
• Dissection in correct planes
• Wide mobilisation of the bladder
• Intra op retrograde filling of bladder
• Cystourethroscopy during surgery
MANAGEMENT
• CONSERVATIVE MANAGEMENT
• MEDICAL THERAPY
• SURGICAL THERAPY
• NONSURGICAL INTERVENTION
CONSERVATIVE MANAGEMENT
• Indications
– Simple fistulae
– <1 cm in size
– Diagnosed within 7 days of index surgery
– Unrelated to carcinoma or radiation
• Continuous bladder drainage
– By transurethral or suprapubic catheter
– Duration- upto 30 days
• Small fistula may resolve spontaneously
• If fistula decrease in size  drainage for additional 2-3 weeks
• If no improvement in 30 days  will need surgery
MEDICAL MANAGEMENT
• Estrogen Replacement Therapy
– Optimize tissue vascularization and healing in postmenopausal
patient
• Local Estrogen Vaginal Cream
– 2-4 gm placed pervaginally at bed time once a week for 4-6 weeks
in those who are hypoestrogenic
• Acidification of urine
– To diminish risk of cystitis, bladder calculi formation
– Vitamin C 500mg orally TDS
• Antibiotics
• Urised
– Combination of antiseptics (methenamine, methylene blue,
phenyl salicylate, benzoic acid) and parasympatholytics (atropine
sulfate, hyoscyamine sulfate)
• Sitz bath
• Barrier ointment such as zinc oxide or vaseline application
– In treatment of perineal and ammoniacal dermatitis
NON SURGICAL INTERVENTION
• ELECTROCAUTERY FULGURATION
– Fistula small in size (pinhole openings
– Vaginal and cystoscopic route  fulguration 
foley’s catheter placement for 2-3 weeks
• FIBRIN GLUE
– useful and safe for intractable fistula
• LASER WELDING with Nd YAG laser
– Fulguration and transurethral catheter for 3 weeks
SURGICAL MANAGEMENT
PRINCIPLES
• Timing of repair
• Route of repair
• Suitable equipment and illumination
• Adequate exposure, patient positioning
• Excision of fistulous tract (controversial)
• Use of suitable suture material
• Sufficient post operative bladder drainage
TIMING OF REPAIR
• Dictum is that best time to repair fistula is at
its first closure during index surgery.
• Obstetric fistula- 3 months following delievery
• Surgical fistula
– if recognized within 48 hours- immediate repair
– Otherwise repaired after 10-12 weeks
• Radiation fistula- after 12 months
PREOPERATIVE CARE
• Improvement of general condition
• Continuous bladder drainage
• Antibiotics
• Estrogen cream
• Topical creams for ammoniacal dermatitis
PREOPERATIVE ASSESSMENT
• Local assessment of the fistula best done 1-3 days
before the repair- fistula status
• Urine routine and microscopy
• Urine culture and sensitivity
• Cystocopy
• Urethroscopy
• Voiding cystourethrogram depending on
• Intravenous urogram cause
• Retrograde pyelogram
• Urodynamic studies
ROUTE OF REPAIR
Depends upon access to the fistula site, mobility
of the vagina and surgeon expertise
SITE APPROACH
LOW FISTULA
Urethral
Juxtaurethral
VAGINAL
CIRCUMFERENTIAL
LOSS OF BLADDER NECK
COMBINED
ABDOMINOVAGINAL
MIDVAGINAL FISTULA TRANSVAGINAL
HIGH VAGINAL FISTULA
Post hysterectomy or juxtacervical
ABDOMINAL OR
VAGINAL APPROACH
PATIENT POSITION
• Dorsal lithotomy position with Standard
Trendelenburg position
• Sim’s position
• Knee chest position
• Jack knife position
Instruments should be fine tipped and long
handled
Suture material
Vicryl 2-0 suture material- bladder and vagina
Polydioxanone 4-0 - ureter
Jack knife position
Dorsal lithotomy position with
Standard trendelenburg
Sim’s position
General concepts of surgery
• First attempt is the best attempt
• Tension free closure
• Water tight closure
• Non overlapping suture lines
• Use of interpositional grafts
• Use of delayed absorbable suture material
REPAIR OF VVF
• Vaginal approach
Flap splitting method
Saucerization
Latzko technique
• Abdominal approach
FLAP SPLITTING TECHNIQUE
Latzko approach
Saucerization
• Original Sim’s Marion technique
• For small fistulae or residual fistulae after
repair
• Edge paring and suturing with
silver wire
Abdominal approach indications
• High inaccessible fistula
• Multiple fistulas
• Involvement of uterus or bowel
• Need for ureteral reimplantation
• Complex fistula
• Associated pelvic pathology
Abdominal repair
Transvesical repair Transperitoneal repair
Combined repair
• For repair of big fistula, postirradiation fistula
• AIM
To support fistula repair
To fill dead space
To bring in new blood supply to area of repair
• GRAFTS
– Martius graft – Labial fat and bulbocavernous muscle
– Gracilis
– Omental graft
– Rectus abdominis
– Peritoneal flap graft
Pedicle interposition grafts
Genital tract fistulas  main
POSTOPERATIVE MANAGEMENT
• Continuous bladder drainage 10-14 days
• Maintain output at 100ml / hr
• Antimicrobials
• Plenty of fluids for continuous bladder drainage
• Watch for any bladder block, fluid balance
DISCHARGE ADVICE:
To pass urine frequently
Avoid intercourse for at least 3 months
To defer pregnancy for at least 1 year
Successful repair should have abdominal delivery
If repair fails, local repair should be reattempted after
3 months
CRITERIA FOR SUCCESSFUL REPAIR
(WHO 2006)
CRITERIA GOOD PROGNOSIS UNCERTAIN PROGNOSIS
NO. OF FISTULA Single Multiple
SITE VVF RVF, MIXED (RVF +VVF)
SIZE <4 cm >4 cm
VAGINAL SCARRING Absent Present
TISSUE LOSS Minimal Extensive
URETER INVOLVEMENT Draining into bladder Draining into vagina
URETHRAL INVOLVEMENT Absent Present
CIRCUMFERENTIAL DEFECT Absent Present
RECTOVAGINAL FISTULA
DEFINITION
• Abnormal communication between the
rectum and vagina with involuntary escape of
flatus and/or feces into the vagina resulting in
fecal incontinence
• Socially disabling condition
ETIOLOGY
I. CONGENITAL
Incomplete partition of cloaca
II. ACQUIRED
• OBSTETRICAL
– Incomplete healing or disruption of primary repaired or
unrepaired recent complete perineal tear (commonest
cause)
– Obstructed labour
– Difficult forceps delievery
– Midline episiotomy
– Instrumental injury during destructive operations
– Develop immediately or 7-10 days after delievery
(common)
• GYNAECOLOGICAL
– Following incomplete healing or repair of old CPT
– Operative injury- in operations like perineorraphy,
repair of enterocele, posterior colpotomy to drain
the pelvic abscess, vaginal reconstructive surgery
– Accidental Trauma- fall on a sharp pointed object
– Malignancy- of vagina, cervix or bowel
– Radiation
– Infections –LGV , tuberculosis
– Inflammatory bowel disease
• Crohn’s disease of lower bowel and rectum > UC
– Diverticulitis of sigmoid colon  abscess
formation  burst into vagina
EVALUATION
Clinical presentation
– Involuntary escape of flatus and/or feces into the vagina
– If fistula is small  incontinence of flatus and loose stool
only but not of hard stool
– Foul smelling vaginal discharge with periodic uncontrolled
escape of gas
– Appear immediately or 7-10 days after delivery
Rectovaginal examination
– Identification of fistula number, site and size
– Assessment of surrounding tissue of fistula
– Contraction of puborectalis muscle and external anal
sphincter should be assessed
– Perineal body is examined
Confirmation
– Thin Probe is passed from the vagina through the
fistulous tract into the rectum/anal canal
– Methylene blue dye test
– Air bubble seen in saline filled vagina after
insertion of air into rectum through Foley’s
catheter
– Examination under
anaesthesia
INVESTIGATIONS
• Barium enema
• Gastrogaffin Enema
• Barium meal
• Barium follow through
• Sigmoidoscopy and proctoscopy with biopsy
• CT scans
• MRI
• Ultrasound
CLASSIFICATION
• Based on anatomical location of vaginal opening
Low - vaginal opening near the posterior fourchette)
Mid (from the level of the cervix to just superior to the
posterior fourchette)
High (the fistula is in the area of the posterior fornix).
• Simple vs Complex
– Simple are small (<2.5cm),
low, due to trauma /infection
– Complex are large, high,
due to IBD, radiation, malignancy
TREATMENT
• PREVENTIVE
– Good intranatal care
– Identification of perineal tear and its effective
repair
– Identification of rectal injury during surgeries and
its effective and appropriate surgery
DEFINITIVE SURGERY
• ROUTE: transvaginal, transanal, and abdominal
approaches
– Determining factors: cause of the fistula, its location and
accessibility, and the status of the anal sphincter.
– Fistula located in lower part of anal canal  transvaginal
route in lithotomy position
– Fistula located high up in apex of vagina  abdominal
approach
• TIMING: Wait 8-12 weeks before surgical intervention
to allow surrounding inflammation to resolve
completely
• Preoperative Mechanical Bowel preparation
• On morning of operation, Tap water enema until it is
clear
Low rectovaginal fistula repair
technique
Small rectovaginal fistula with
proposed line of initial incision
Excision of fistulous tract.
Extramucosal placement of
sutures in wall of anterior
anal canal
The lower portions of the puborectalis muscle and the external anal sphincter are approximated
to add a third layer in the closure which helps to reconstitute the anterior rectal wall
Fistula converted to fourth degree
perineal tear.
• If fistula is so close to the external anal sphincter that the
closure is difficult
Bridge of skin,
sphincter and
perineal body is
divided
Excision of fistulous tract
Mobilization of posterior vaginal wall from
Anterior anal canal
Converting RVF into 4th degree perineal tear
1
2
3 4 5
Reconstructed
perineal body
with subcuticular
approximation
of skin of perineum
Reanastomosis of retracted
external anal sphincter in
End to end fashion
with surgeon's left index
finger in the anal canal
Two layer reconstruction of anal canal
Initial layer- approximating mucosa
of anal canal
Second layer approximating retracted
end of IAS inverting initial layer
SUMMARY
• A thoughtful preoperative workup with extensive
preoperative counseling regarding expectations and
possible outcomes is crucial for the ultimate satisfaction
of the patient
• Mechanical bowel preparation, perioperative antibiotic
prophylaxis, and attention to postoperative diet and
stool consistency management are important
• Rectovaginal fistula repair requires thorough surgical
planning, careful attention to detail, and a meticulous
operative technique to provide the patient with optimal
results.
• Rectovaginal fistula repair requires careful attention to
sharp dissection, gentle tissue handling, wide
mobilization, meticulous hemostasis, and a tension-free
closure.
THANK YOU

Más contenido relacionado

La actualidad más candente

Principles of management of vvf
Principles of management of vvfPrinciples of management of vvf
Principles of management of vvfHabibaIsah
 
Genital tract fistula
Genital tract fistulaGenital tract fistula
Genital tract fistulaobgymgmcri
 
Ureteric injury
Ureteric injuryUreteric injury
Ureteric injurySagnik24
 
Rectovaginal fistulas
Rectovaginal fistulasRectovaginal fistulas
Rectovaginal fistulasmagdy abdel
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancydrmcbansal
 
Vesico vaginal fistula
Vesico vaginal fistulaVesico vaginal fistula
Vesico vaginal fistulaseema nishad
 
FOTHERGIL'S OPERATION
FOTHERGIL'S  OPERATION  FOTHERGIL'S  OPERATION
FOTHERGIL'S OPERATION Shivamurthy Hm
 
Manchester repair (Fothergill’s Operation)
Manchester repair (Fothergill’s Operation)Manchester repair (Fothergill’s Operation)
Manchester repair (Fothergill’s Operation)Yapa
 
Management of genitourinary fistula
Management of genitourinary fistulaManagement of genitourinary fistula
Management of genitourinary fistuladrmcbansal
 
Postmenopausal bleeding
Postmenopausal bleedingPostmenopausal bleeding
Postmenopausal bleedingManahil Jamil
 
Conservative surgeries for genital prolapse
Conservative surgeries for genital prolapseConservative surgeries for genital prolapse
Conservative surgeries for genital prolapseNikhil Bansal
 
FEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANI
FEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANIFEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANI
FEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANIDR SHASHWAT JANI
 
Cutaneous cesarean scar endometriosis
Cutaneous  cesarean  scar   endometriosisCutaneous  cesarean  scar   endometriosis
Cutaneous cesarean scar endometriosismuhammad al hennawy
 

La actualidad más candente (20)

Principles of management of vvf
Principles of management of vvfPrinciples of management of vvf
Principles of management of vvf
 
Genital tract fistula
Genital tract fistulaGenital tract fistula
Genital tract fistula
 
Post Menopausal Bleeding
Post Menopausal BleedingPost Menopausal Bleeding
Post Menopausal Bleeding
 
Vesico vaginal fistula
Vesico vaginal fistulaVesico vaginal fistula
Vesico vaginal fistula
 
Ureteric injury
Ureteric injuryUreteric injury
Ureteric injury
 
Rectovaginal fistulas
Rectovaginal fistulasRectovaginal fistulas
Rectovaginal fistulas
 
Ectopic pregnancy
Ectopic pregnancyEctopic pregnancy
Ectopic pregnancy
 
Vesico vaginal fistula
Vesico vaginal fistulaVesico vaginal fistula
Vesico vaginal fistula
 
FOTHERGIL'S OPERATION
FOTHERGIL'S  OPERATION  FOTHERGIL'S  OPERATION
FOTHERGIL'S OPERATION
 
Manchester repair (Fothergill’s Operation)
Manchester repair (Fothergill’s Operation)Manchester repair (Fothergill’s Operation)
Manchester repair (Fothergill’s Operation)
 
Management of genitourinary fistula
Management of genitourinary fistulaManagement of genitourinary fistula
Management of genitourinary fistula
 
Cervical cerclage procedure
Cervical cerclage procedureCervical cerclage procedure
Cervical cerclage procedure
 
Postmenopausal bleeding
Postmenopausal bleedingPostmenopausal bleeding
Postmenopausal bleeding
 
Benign Cervical Lesions
Benign Cervical LesionsBenign Cervical Lesions
Benign Cervical Lesions
 
Conservative surgeries for genital prolapse
Conservative surgeries for genital prolapseConservative surgeries for genital prolapse
Conservative surgeries for genital prolapse
 
Uterine compression sutures
Uterine compression suturesUterine compression sutures
Uterine compression sutures
 
Benign ovarian tumours
Benign ovarian tumoursBenign ovarian tumours
Benign ovarian tumours
 
Ovarian tumors
Ovarian tumorsOvarian tumors
Ovarian tumors
 
FEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANI
FEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANIFEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANI
FEMALE PELVIC APPLIED ANATOMY BY DR SHASHWAT JANI
 
Cutaneous cesarean scar endometriosis
Cutaneous  cesarean  scar   endometriosisCutaneous  cesarean  scar   endometriosis
Cutaneous cesarean scar endometriosis
 

Similar a Genital tract fistulas main

Obstetric fistula
Obstetric fistulaObstetric fistula
Obstetric fistulaAdaiah
 
Obstetric fistula
Obstetric fistulaObstetric fistula
Obstetric fistulakayasa07
 
Bladder and injuries
Bladder and injuriesBladder and injuries
Bladder and injuriesmandybhandal1
 
URETHRAL STRICTURE MAIN.pptx
URETHRAL STRICTURE MAIN.pptxURETHRAL STRICTURE MAIN.pptx
URETHRAL STRICTURE MAIN.pptx30366994
 
GENITO-URINARY FISTULA.pptx
GENITO-URINARY FISTULA.pptxGENITO-URINARY FISTULA.pptx
GENITO-URINARY FISTULA.pptxSahilVerma19852
 
Bedside teaching vvf
Bedside teaching vvfBedside teaching vvf
Bedside teaching vvfKhusbuLama
 
3rd Stage Complication of Labour
3rd Stage Complication of Labour3rd Stage Complication of Labour
3rd Stage Complication of LabourNur Izzatul Najwa
 
oshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptxoshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptxahmed eshiba
 
OBSTETRIC FISTULA.pptx
OBSTETRIC FISTULA.pptxOBSTETRIC FISTULA.pptx
OBSTETRIC FISTULA.pptxCaiusMbao
 
Ureter anatomy injury n diversion
Ureter anatomy injury n diversionUreter anatomy injury n diversion
Ureter anatomy injury n diversiondrmcbansal
 
Management Of Fibroids
Management Of FibroidsManagement Of Fibroids
Management Of FibroidsHari Dev
 
Lower urinary tract disorders kemboi
Lower urinary tract disorders kemboiLower urinary tract disorders kemboi
Lower urinary tract disorders kemboikemboiarn
 
Inguinal hernia ; Treatment & Pathophisiology presentation
Inguinal hernia ; Treatment & Pathophisiology presentationInguinal hernia ; Treatment & Pathophisiology presentation
Inguinal hernia ; Treatment & Pathophisiology presentationMohammad ali Shariatyfar
 

Similar a Genital tract fistulas main (20)

Obstetric fistula
Obstetric fistulaObstetric fistula
Obstetric fistula
 
VVF final.pptx
VVF final.pptxVVF final.pptx
VVF final.pptx
 
Obstetric fistula
Obstetric fistulaObstetric fistula
Obstetric fistula
 
Bladder and injuries
Bladder and injuriesBladder and injuries
Bladder and injuries
 
urinary tract fistula
urinary tract fistulaurinary tract fistula
urinary tract fistula
 
URETHRAL STRICTURE MAIN.pptx
URETHRAL STRICTURE MAIN.pptxURETHRAL STRICTURE MAIN.pptx
URETHRAL STRICTURE MAIN.pptx
 
Genital fistula.pptx
Genital fistula.pptxGenital fistula.pptx
Genital fistula.pptx
 
Uterine Fistula
Uterine FistulaUterine Fistula
Uterine Fistula
 
GENITO-URINARY FISTULA.pptx
GENITO-URINARY FISTULA.pptxGENITO-URINARY FISTULA.pptx
GENITO-URINARY FISTULA.pptx
 
Bedside teaching vvf
Bedside teaching vvfBedside teaching vvf
Bedside teaching vvf
 
3rd Stage Complication of Labour
3rd Stage Complication of Labour3rd Stage Complication of Labour
3rd Stage Complication of Labour
 
Cesarean delivery
Cesarean deliveryCesarean delivery
Cesarean delivery
 
oshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptxoshiba prune belly syndrome.pptx
oshiba prune belly syndrome.pptx
 
Posterior urethral valve
Posterior urethral valvePosterior urethral valve
Posterior urethral valve
 
OBSTETRIC FISTULA.pptx
OBSTETRIC FISTULA.pptxOBSTETRIC FISTULA.pptx
OBSTETRIC FISTULA.pptx
 
Ureter anatomy injury n diversion
Ureter anatomy injury n diversionUreter anatomy injury n diversion
Ureter anatomy injury n diversion
 
Management Of Fibroids
Management Of FibroidsManagement Of Fibroids
Management Of Fibroids
 
Lower urinary tract disorders kemboi
Lower urinary tract disorders kemboiLower urinary tract disorders kemboi
Lower urinary tract disorders kemboi
 
Inguinal hernia ; Treatment & Pathophisiology presentation
Inguinal hernia ; Treatment & Pathophisiology presentationInguinal hernia ; Treatment & Pathophisiology presentation
Inguinal hernia ; Treatment & Pathophisiology presentation
 
ENDOMETRIOSIS
ENDOMETRIOSIS ENDOMETRIOSIS
ENDOMETRIOSIS
 

Último

Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.aarjukhadka22
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingAnonymous
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyMedicoseAcademics
 
concept of total quality management (TQM).
concept of total quality management (TQM).concept of total quality management (TQM).
concept of total quality management (TQM).kishan singh tomar
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxkitati1
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfMedicoseAcademics
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisNilofarRasheed1
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationMedicoseAcademics
 

Último (20)

Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
Bulimia nervosa ( Eating Disorders) Mental Health Nursing.
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
General_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_WellbeingGeneral_Studies_Presentation_Health_and_Wellbeing
General_Studies_Presentation_Health_and_Wellbeing
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
Female Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before PregnancyFemale Reproductive Physiology Before Pregnancy
Female Reproductive Physiology Before Pregnancy
 
concept of total quality management (TQM).
concept of total quality management (TQM).concept of total quality management (TQM).
concept of total quality management (TQM).
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
Microbiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptxMicrobiology lecture presentation-1.pptx
Microbiology lecture presentation-1.pptx
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
Pregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdfPregnacny, Parturition, and Lactation.pdf
Pregnacny, Parturition, and Lactation.pdf
 
Physiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid ArthritisPhysiotherapy Management of Rheumatoid Arthritis
Physiotherapy Management of Rheumatoid Arthritis
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 
Cone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptxCone beam CT: concepts and applications.pptx
Cone beam CT: concepts and applications.pptx
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxationPhysiology of Smooth Muscles -Mechanics of contraction and relaxation
Physiology of Smooth Muscles -Mechanics of contraction and relaxation
 

Genital tract fistulas main

  • 1. GENITAL TRACT FISTULAS Dr. Shaheen Hokabaj C. S. I, Mysore
  • 2. DEFINITIONDEFINITION • A FISTULA is an abnormal communication between two or more epithelial surfaces • GENITAL TRACT FISTULA is an abnormal communication between epithelial surfaces of Urinary  Genital Tract Intestine  Genital Tract Skin  Genital Tract
  • 3. GENITAL TRACT FISTULAS CLASSIFICATION I II III I. GENITOURINARY FISTULAS II. INTESTINO-GENITAL FISTULAS III. GENITAL TRACT- SKIN FISTULA IV. URO-INTESTINO- GENITAL (COMPOUND) V. GENITAL TRACT FISTULA, UNSPECIFIED
  • 5. GENITOURINARY FISTULA • Is an abnormal communication between urinary and genital tract with involuntary escape of urine into the genital tract • 2-7 Million women affected worldwide • 0.2-1% of gynecologic admission
  • 6. TYPES BLADDER URETER URETHRA Vesicovaginal Ureterovaginal Urethrovaginal Vesicouterine Ureterouterine Vesicocervical Ureterocervical Vesicourethro- vaginal
  • 9. AETIOLOGY • CONGENITAL MALFORMATION – Aberrant ureter and persisting urogenital sinus – Mostly associated with other urinary tract abnormalities • ACCIDENTS – Road traffic accident  Crush injuries to the pelvis  bone fragments can cause perforation of the bladder or urethra – Avulsion of urethra – Fall on pointed object
  • 10. • OBSTETRICAL CAUSES In the developing countries- commonest cause accounts for 80-90% of cases (developed 5-15%) – ISCHEMIC NECROTIC OBSTETRIC FISTULA Prolonged Obstructed labour - CPD and malpresentation  trigone of bladder is nipped between presenting part and pubic symphysis  ischemic tissue necrosis  sloughing genitourinary fistula - Slough take some days to separate  thus incontinence develops 7-10 days after delivery
  • 11. Obstructed labor Trigone of bladder is nipped in between pubic symphysis and presenting Part Compression ischemia Necrosis Fistula formation 7-10th postnatal day
  • 12. Fetal death Fistula formationFecal incontinence Urinary incontinence Complex urological injury Vaginal scarring and stenosis Secondary infertility Chronic skin irritation, Offensive odours Stigmatization Isolation and loss of social support Divorce or separation Worsening poverty Worsening malnutrition Obstructed Labor Injury Complex
  • 13. • OBSTETRICAL CAUSES - TRAUMATIC FISTULA – Instrumental Vaginal delivery such as destructive operations or forceps specially with kielland. • Injury inflicted by bony spicule of the fetal skull in craniotomy operation – In Caesarean section • At risk in patient with previous LSCS • if bladder is caught in the suture can cause ischemia leading to fistula formation - Ligation of main branch of uterine vessels in case of hemorrhage due to lateral extension of transverse incision in LSCS Ureters are at risk of injury - Rupture of scar of previous LSCS can implicate adherent bladder base In such direct traumatic injury, fistula and incontinence follows soon after delivery
  • 14. • GYNAECOLOGICAL CAUSES OPERATIVE INJURY – In developed countries it accounts for 70% of fistulas – In nearly all gynaecological operations one or other part of the urinary tract is in danger – URETER- is at risk in total hysterectomy especially radical hysterectomy, removal of broad ligament tumours - Risk of ureteral injury was seven times greater with laparoscopic procedures than with open procedures - URETHRA- is threatened during anterior colporrhaphy and sling operation
  • 15. Post surgical fistula - Pathophysiology Unrecognized bladder injury during difficult hysterectomy or cesarean Or surgery involving anterior vaginal wall Post hysterectomy fistula – located above the interureteric ridge Overvigorous blunt dissection of bladder from the uterus Result in tear in Post bladder wall or devascularisation Tissue ischemia, necrosis Fistula Vaginal cuff suture – Incorporated into bladder 1. 2.
  • 16. • MALIGNANCY- – Advanced carcinoma of cervix, vagina or bladder  may produce fistula by direct spread • RADIOTHERAPY – Excessive, misapplied and even well applied irradiation for pelvic malignancy esp carcinoma of cervix causes endarteritis obliterans ischaemic necrosis  fistula – Late complication- takes 1-2 years to produce such fistula • INFECTIVE – Vaginal foreign bodies, forgotten and retained pessaries – Chronic granulomatous lesions such as genital tuberculosis, LGV, schistosomiasis, actinomycosis – rare causes of fistula
  • 17. VESICOVAGINAL FISTULA (The Commonest) VVF is an abnormal communication between bladder and vagina and the urine escapes into the vagina resulting in true incontinence
  • 18. HISTORICAL PERSPECTIVE • The first record of a VVF is found in the writings of ancient Hindu medicine, the Vedas and Upavedas. • Avicenna, a Persian physician, was the first known writer to mention the occurrence of a VVF and also recognized the association between such a lesion and labor • James Marion Sims, 1852- Father of surgery of VVF first published his method for the surgical treatment of VVF using a transvaginal approach • Trendelenburg in 1888 successfully performed the transabdominal VVF repair.
  • 19. Predisposing factors • History of pelvic irradiation • Cesarean section • Endometriosis • Prior pelvic surgery • Pelvic inflammatory disease • Diabetes mellitus • Concurrent infection • Vasculopathies • Tobacco abuse
  • 20. Classification of VVF • Simple - Fistula <2-3 cm in size - Supratrigonal (near the cuff) - No history of radiation or pelvic malignancy - Vaginal length is normal - Healthy tissue - Good access • Complicated - Fistula >3 cm in size - Fistula distant from cuff or has trigonal involved - H/o previous radiotherapy and Pelvic malignancy is present - Vaginal length is shortened - Associated with scarring - Involving urethra, vesical neck, ureter, intestinal fistula - Previous unsuccessful attempt at repairs
  • 21. Classification according to the site of fistula I. High fistula 1. Juxtacervical 2. Vault (vesicouterine) II. Mid Vaginal fistula III. Low fistula a. Bladder neck- Urethra intact b. Urethral involvement- segmental(Partial bladder neck loss c. Complete bladder neck loss- circumferential fistula IV. Urethrovaginal fistula A small fistula below the bladder neck is incompetent V. Massive vaginal fistula encompasses all three levels and often includes one or both ureters in addition
  • 22. Classification according to the size • Small <2 cm • Medium 2-3 cm • Large 4-5 cm • Extensive >6 cm
  • 23. EVALUATION OF VVF • History • General and Genital Examination • Confirmation of diagnosis • Radiological Evaluation • Cystoscopic Evaluation
  • 24. HISTORY • VVF is usually presented with continuous escape of urine per vaginum ( true Incontinence)- CLASSIC SYMPTOM. • Patient got no urge to void urine • Small fistula- escape of urine occur in certain position and can also pass urine normally • Leakage of urine following surgical injury occurs from the first postoperative day • Obstetrical fistula- symptoms take 7-14 days to appear • Urethral fistula situated high up- may present with stress incontinence • Vesicocervical and vesicouterine fistulae- may hold urine at the level of uterine isthmus and remain continent • Menouria- cyclical hematuria at the time of menstruation is present • Pruritis vulvae, perineal skin irritation, fungal infection due to constant wetness
  • 25. HISTORY • Age and socioeconomic status of women • Previous gynaecological surgery/radiotherapy • Previous history of prolonged labour/ trauma during childbirth If previous delivery is suspected as cause  detailed obstetric history should be gathered. • Time of occurrence • History of urine leakage • Timing of leakage, amount of leakage • Voiding per urethra apart from the leakage • Any leakage of faeces, gas leakage • Any attempt of previous repair of fistula
  • 26. EXAMINATION • General Examination • Per Abdomen examination- surgical scars • Vulval Inspection – Escape of watery discharge per vaginam of ammoniacal smell is characteristic – Sodden and excoriation of the vulval skin – Varying degree of perineal tears may be present • Per Speculum Examination – Sim’s position and Sim’s Speculum – Any pooling of fluid in the vagina – Site, size, number of fistula – Assess quality of surrounding tissue; tissue mobility – Bladder mucosa may be visibly prolapsed through a big fistula
  • 27. • Tiny fistula- – is evidenced by a puckered area of vaginal mucosa – when women coughs while lying in sims position bubbles are seen coming through tiny fistula • Per Vaginal examination – Palpate anterior and posterior vaginal wall – Gives better idea of fistula – Assessment of tissue mobility, size, site, determination of the degree of tissue inflammation, edema and infection Sims position Sims speculum
  • 28. CONFIRMATION OF DIAGNOSIS • Dye test Methylene blue introduced into bladder by a catheter  dye will be seen coming through the opening • Three Swab test /Tampon test of Moir • Double dye test Give patient oral phenazoyridine, fill the bladder with the blue tinted solution and insert a tampon. Presence of blue staining suggest- VVF or urethrovaginal fistula Red staining (pyridium) suggest ureterovaginal fistula • Metal catheter passed through external urethral meatus into the bladder when comes out through the fistula in vagina confirms VVF and patency of urethra • Examination under anaesthesia
  • 29. Midvaginal obstetric fistula- metal catheter is passed through it
  • 30. 3 swab test (Vaginal Gauze test) • Three separate sponge swabs are placed into the vagina one above the another • The bladder is then filled with a coloured agent such as methylene blue through a rubber catheter, and patient asked to do some exertional manuevers and then the swabs are removed after 10 mins.
  • 31. Result of 3 swab test 1. Discolouration of topmost or middle swab  vesicovaginal fistula 2. Uppermost swab wetting but not discolouration  Ureterovaginal fistula 3. Discolouration of lower most swab but upper two swabs remain dry  Urethrovaginal fistula 1 2 3
  • 32. Laboratory studies • Vaginal vault fluid collection – Tested for urea, creatinine and potassium – To determine likelihood of diagnosis of VVF – Rule out vaginitis • Urine C/S • Biopsy of fistula tract/ urine cytology if suspicious of malignancy
  • 33. Imaging studies • Radiologic studies are recommended prior to surgical repair of a vesicovaginal fistula to fully assess the defect and exclude the presence of multiple fistulae • Intravenous urography- for the diagnosis of ureterovaginal fistula • Retrograde pyelography- if IVP negative and high suspicion of ureterovaginal fistula • Cystography- done in complex fistula • Sinography (fistulography)- for intestinogenital fistula • HSG- for diagnosis of vesicouterine fistula when patient presents with symptoms of menouria • Ultrasound, CT,MRI- done for evaluation of complex fistulae
  • 34. Diagnostic procedures for VVF • Cystoscopic Examination • Cystoscopic Examination using CO2 gas (FLAT TIRE sign) • Combined Vaginoscopy- cystoscopy – Transillumination of the bladder or vagina by turning off the vaginal or bladder light allows for easier identification in difficult cases • Colour Doppler ultrasonography with contrast media of the urinary bladder in cases where cystoscopic evaluation is equivocal • Fistulograms- indicated if conservative therapy is planned.
  • 35. Cystogram showing extravasation of dye from bladder into vaginal canal Cystoscopic view of fistula
  • 36. PREVENTION OBSTETRIC FISTULA • PRIMORDIAL PREVENTION – Girl’s Education – Women’s Empowerment – Increase the age of marriage – Nutritious diet since childhood • PRIMARY PREVENTION – Availability of family planning method services – Strategy to make motherhood safer should be followed – Good antenatal care – Watchful progress of labour – Trained birth attendants – Transportation and emergency obstetric care
  • 37. PREVENTION • SECONDARY PREVENTION – Early recognition of CPD and prevention of obstructed labour – LSCS in indicated cases – Avoidance of difficult forceps and destructive operations – Prolonged Catheter drainage in prolonged or obstructed labour. RADIATION FISTULA • Proper dose and technique of irradiation • Packing of the vagina • Midline block
  • 38. If you suspect fistula is going to form following obstructed labour or destructive operation – Insert an in dwelling catheter and start continuous closed drainage – Ensure a high fluid intake – Mobilize her early, always keeping the bag below her bladder – After 7-10 days examine her anterior vaginal wall in Sim’s position with speculum • If her bladder is still bruised or necrotic – Leave her catheter in and remove only when healthy tissue is seen in next examination
  • 39. PREVENTION SURGICAL FISTULA • Adequate exposure during surgery • Minimize bleeding and hematoma formation • Dissection in correct planes • Wide mobilisation of the bladder • Intra op retrograde filling of bladder • Cystourethroscopy during surgery
  • 40. MANAGEMENT • CONSERVATIVE MANAGEMENT • MEDICAL THERAPY • SURGICAL THERAPY • NONSURGICAL INTERVENTION
  • 41. CONSERVATIVE MANAGEMENT • Indications – Simple fistulae – <1 cm in size – Diagnosed within 7 days of index surgery – Unrelated to carcinoma or radiation • Continuous bladder drainage – By transurethral or suprapubic catheter – Duration- upto 30 days • Small fistula may resolve spontaneously • If fistula decrease in size  drainage for additional 2-3 weeks • If no improvement in 30 days  will need surgery
  • 42. MEDICAL MANAGEMENT • Estrogen Replacement Therapy – Optimize tissue vascularization and healing in postmenopausal patient • Local Estrogen Vaginal Cream – 2-4 gm placed pervaginally at bed time once a week for 4-6 weeks in those who are hypoestrogenic • Acidification of urine – To diminish risk of cystitis, bladder calculi formation – Vitamin C 500mg orally TDS • Antibiotics • Urised – Combination of antiseptics (methenamine, methylene blue, phenyl salicylate, benzoic acid) and parasympatholytics (atropine sulfate, hyoscyamine sulfate) • Sitz bath • Barrier ointment such as zinc oxide or vaseline application – In treatment of perineal and ammoniacal dermatitis
  • 43. NON SURGICAL INTERVENTION • ELECTROCAUTERY FULGURATION – Fistula small in size (pinhole openings – Vaginal and cystoscopic route  fulguration  foley’s catheter placement for 2-3 weeks • FIBRIN GLUE – useful and safe for intractable fistula • LASER WELDING with Nd YAG laser – Fulguration and transurethral catheter for 3 weeks
  • 44. SURGICAL MANAGEMENT PRINCIPLES • Timing of repair • Route of repair • Suitable equipment and illumination • Adequate exposure, patient positioning • Excision of fistulous tract (controversial) • Use of suitable suture material • Sufficient post operative bladder drainage
  • 45. TIMING OF REPAIR • Dictum is that best time to repair fistula is at its first closure during index surgery. • Obstetric fistula- 3 months following delievery • Surgical fistula – if recognized within 48 hours- immediate repair – Otherwise repaired after 10-12 weeks • Radiation fistula- after 12 months
  • 46. PREOPERATIVE CARE • Improvement of general condition • Continuous bladder drainage • Antibiotics • Estrogen cream • Topical creams for ammoniacal dermatitis
  • 47. PREOPERATIVE ASSESSMENT • Local assessment of the fistula best done 1-3 days before the repair- fistula status • Urine routine and microscopy • Urine culture and sensitivity • Cystocopy • Urethroscopy • Voiding cystourethrogram depending on • Intravenous urogram cause • Retrograde pyelogram • Urodynamic studies
  • 48. ROUTE OF REPAIR Depends upon access to the fistula site, mobility of the vagina and surgeon expertise SITE APPROACH LOW FISTULA Urethral Juxtaurethral VAGINAL CIRCUMFERENTIAL LOSS OF BLADDER NECK COMBINED ABDOMINOVAGINAL MIDVAGINAL FISTULA TRANSVAGINAL HIGH VAGINAL FISTULA Post hysterectomy or juxtacervical ABDOMINAL OR VAGINAL APPROACH
  • 49. PATIENT POSITION • Dorsal lithotomy position with Standard Trendelenburg position • Sim’s position • Knee chest position • Jack knife position Instruments should be fine tipped and long handled Suture material Vicryl 2-0 suture material- bladder and vagina Polydioxanone 4-0 - ureter
  • 50. Jack knife position Dorsal lithotomy position with Standard trendelenburg Sim’s position
  • 51. General concepts of surgery • First attempt is the best attempt • Tension free closure • Water tight closure • Non overlapping suture lines • Use of interpositional grafts • Use of delayed absorbable suture material
  • 52. REPAIR OF VVF • Vaginal approach Flap splitting method Saucerization Latzko technique • Abdominal approach
  • 55. Saucerization • Original Sim’s Marion technique • For small fistulae or residual fistulae after repair • Edge paring and suturing with silver wire
  • 56. Abdominal approach indications • High inaccessible fistula • Multiple fistulas • Involvement of uterus or bowel • Need for ureteral reimplantation • Complex fistula • Associated pelvic pathology
  • 57. Abdominal repair Transvesical repair Transperitoneal repair Combined repair
  • 58. • For repair of big fistula, postirradiation fistula • AIM To support fistula repair To fill dead space To bring in new blood supply to area of repair • GRAFTS – Martius graft – Labial fat and bulbocavernous muscle – Gracilis – Omental graft – Rectus abdominis – Peritoneal flap graft Pedicle interposition grafts
  • 60. POSTOPERATIVE MANAGEMENT • Continuous bladder drainage 10-14 days • Maintain output at 100ml / hr • Antimicrobials • Plenty of fluids for continuous bladder drainage • Watch for any bladder block, fluid balance DISCHARGE ADVICE: To pass urine frequently Avoid intercourse for at least 3 months To defer pregnancy for at least 1 year Successful repair should have abdominal delivery If repair fails, local repair should be reattempted after 3 months
  • 61. CRITERIA FOR SUCCESSFUL REPAIR (WHO 2006) CRITERIA GOOD PROGNOSIS UNCERTAIN PROGNOSIS NO. OF FISTULA Single Multiple SITE VVF RVF, MIXED (RVF +VVF) SIZE <4 cm >4 cm VAGINAL SCARRING Absent Present TISSUE LOSS Minimal Extensive URETER INVOLVEMENT Draining into bladder Draining into vagina URETHRAL INVOLVEMENT Absent Present CIRCUMFERENTIAL DEFECT Absent Present
  • 63. DEFINITION • Abnormal communication between the rectum and vagina with involuntary escape of flatus and/or feces into the vagina resulting in fecal incontinence • Socially disabling condition
  • 64. ETIOLOGY I. CONGENITAL Incomplete partition of cloaca II. ACQUIRED • OBSTETRICAL – Incomplete healing or disruption of primary repaired or unrepaired recent complete perineal tear (commonest cause) – Obstructed labour – Difficult forceps delievery – Midline episiotomy – Instrumental injury during destructive operations – Develop immediately or 7-10 days after delievery (common)
  • 65. • GYNAECOLOGICAL – Following incomplete healing or repair of old CPT – Operative injury- in operations like perineorraphy, repair of enterocele, posterior colpotomy to drain the pelvic abscess, vaginal reconstructive surgery – Accidental Trauma- fall on a sharp pointed object – Malignancy- of vagina, cervix or bowel – Radiation – Infections –LGV , tuberculosis – Inflammatory bowel disease • Crohn’s disease of lower bowel and rectum > UC – Diverticulitis of sigmoid colon  abscess formation  burst into vagina
  • 66. EVALUATION Clinical presentation – Involuntary escape of flatus and/or feces into the vagina – If fistula is small  incontinence of flatus and loose stool only but not of hard stool – Foul smelling vaginal discharge with periodic uncontrolled escape of gas – Appear immediately or 7-10 days after delivery Rectovaginal examination – Identification of fistula number, site and size – Assessment of surrounding tissue of fistula – Contraction of puborectalis muscle and external anal sphincter should be assessed – Perineal body is examined
  • 67. Confirmation – Thin Probe is passed from the vagina through the fistulous tract into the rectum/anal canal – Methylene blue dye test – Air bubble seen in saline filled vagina after insertion of air into rectum through Foley’s catheter – Examination under anaesthesia
  • 68. INVESTIGATIONS • Barium enema • Gastrogaffin Enema • Barium meal • Barium follow through • Sigmoidoscopy and proctoscopy with biopsy • CT scans • MRI • Ultrasound
  • 69. CLASSIFICATION • Based on anatomical location of vaginal opening Low - vaginal opening near the posterior fourchette) Mid (from the level of the cervix to just superior to the posterior fourchette) High (the fistula is in the area of the posterior fornix). • Simple vs Complex – Simple are small (<2.5cm), low, due to trauma /infection – Complex are large, high, due to IBD, radiation, malignancy
  • 70. TREATMENT • PREVENTIVE – Good intranatal care – Identification of perineal tear and its effective repair – Identification of rectal injury during surgeries and its effective and appropriate surgery
  • 71. DEFINITIVE SURGERY • ROUTE: transvaginal, transanal, and abdominal approaches – Determining factors: cause of the fistula, its location and accessibility, and the status of the anal sphincter. – Fistula located in lower part of anal canal  transvaginal route in lithotomy position – Fistula located high up in apex of vagina  abdominal approach • TIMING: Wait 8-12 weeks before surgical intervention to allow surrounding inflammation to resolve completely • Preoperative Mechanical Bowel preparation • On morning of operation, Tap water enema until it is clear
  • 72. Low rectovaginal fistula repair technique Small rectovaginal fistula with proposed line of initial incision Excision of fistulous tract.
  • 73. Extramucosal placement of sutures in wall of anterior anal canal
  • 74. The lower portions of the puborectalis muscle and the external anal sphincter are approximated to add a third layer in the closure which helps to reconstitute the anterior rectal wall
  • 75. Fistula converted to fourth degree perineal tear. • If fistula is so close to the external anal sphincter that the closure is difficult Bridge of skin, sphincter and perineal body is divided Excision of fistulous tract Mobilization of posterior vaginal wall from Anterior anal canal Converting RVF into 4th degree perineal tear 1 2
  • 76. 3 4 5 Reconstructed perineal body with subcuticular approximation of skin of perineum Reanastomosis of retracted external anal sphincter in End to end fashion with surgeon's left index finger in the anal canal Two layer reconstruction of anal canal Initial layer- approximating mucosa of anal canal Second layer approximating retracted end of IAS inverting initial layer
  • 77. SUMMARY • A thoughtful preoperative workup with extensive preoperative counseling regarding expectations and possible outcomes is crucial for the ultimate satisfaction of the patient • Mechanical bowel preparation, perioperative antibiotic prophylaxis, and attention to postoperative diet and stool consistency management are important • Rectovaginal fistula repair requires thorough surgical planning, careful attention to detail, and a meticulous operative technique to provide the patient with optimal results. • Rectovaginal fistula repair requires careful attention to sharp dissection, gentle tissue handling, wide mobilization, meticulous hemostasis, and a tension-free closure.

Notas del editor

  1. Remember 2 golden rules 1st rule: urine may escape from ureter  tube, uterus, cervix, vaginabladder  tube, uterus, cervix, vaginaurethra  always vaginal. 2nd rule in naming a fistula,Part of the urinary tract is 1st to be described
  2. In developing countries obstructed labour is a common problem as women are economically underpriviledged, illiterate, married early, poor accesss to family planning and medical services, teenage pregnancy, antenatal careAndroid pelvis, malnutrition, orthopedic disorders like rickets, hydrocephalus causes dystocia
  3. Lower end of the ureter, bladder base and urethra may be directly injured by instruments
  4. incidence of VVF after hysterectomy is approximately one in 1,300 surgeries- MOST COMMON WITH LAP HYSTER TAH VAGINAL HYSTERECTOMYCan be damaged at pelvic brim during division and ligature of infundibulopelvic ligamentLower ureter – is at risk during vaginal hysterectomy and prolapse repair operation
  5. Malignancy and radiation accounts for about 5% of total cases in developed countried.Point A- 2 cm cephalic and 2 cm lateral to external os, 7000-8000 cgyPoint B- 2 cm cephalic and 5 cm lateral in same plane 2000cGy
  6. Gynaecologic fistula are generally classified as simple and complicated..and they have important implication in surgical approach and prognosis. Eg simple VVF have uncomplicated surgical approach with good prognosis
  7. Obstetric fistulae are usually categorized according to their cause, complexity and site of obstruction.Posthysterectomy fistula are usually supratrigonal medial to both ureteric orifices and within the vaginal vaultObstetric causes fistula are amore distal, larger and are more commonly associated with urethral injury.Juxtacervical (close to the cervix)- communication is between the supratrigonal region of bladder and the vagina (vault fistula)Mid vaginal- between trigone of bladder and vaginaJuxtaurethral- between neck of the bladder and vagina. Sometimes include upper urethaSubsymphyisial- circumferential loss of tissue in the region of bladder neck and urethra. Fistula margin is fixed to the bladder.
  8. Detailed obstetric history include- parity, duration of labour, vaginal or caserean, instrumental vaginal, weight of the baby, where was baby delieverd- hospital or home?Poor young women there is increased incidence of CPD and VVF due to early age of marriage, teenage pregnancy, malnutrition, pelvic bone immaturity, reduced birth canal size before the age of 18Prolonged labouresp 2nd stage  can lead to VVF; History of any obstructed labour should be extractedPPH and spesis are associated with poor wound healing and make patient prone for developing VVFTiming- continous, walking, lying down, stress incontinence, Amount of leakage depend on size and site of fistulaDetailed obstetric history include- parity, duration of labour, vaginal or caserean, instrumental vaginal, weight of the baby, where was baby delieverd- hospital or home?Poor young women there is increased incidence of CPD and VVF due to early age of marriage, teenage pregnancy, malnutrition, pelvic bone immaturity, reduced birth canal size before the age of 18Prolonged labouresp 2nd stage  can lead to VVF; History of any obstructed labour should be extractedPPH and spesis are associated with poor wound healing and make patient prone for developing VVFTiming- continous, walking, lying down, stress incontinence, Amount of leakage depend on size and site of fistula
  9. General- ht, wt, bmi, pallor, signs of malnutritionSim’s position- pt lie on left side with left leg straight and right leg flexed at hip and knee vagina becomes ballooned up due to negative suction and give better view of anterior vaginal wallPV digital examination gives better idea than speculum examination for the assessment of all features seen by speculum.
  10. Urine c/s if positive should be treated prior to surgery
  11. Cystoscopic examination is used to determine the number, location and proximity to ureteric orifices, to identify and remove abnormal entities such as calculi or suture in bladderCystoscopic examination using co2 gas- vagina is filled with water or NACL, the infusion of gas through the urethra with cystoscope produces air bubbled in the vaginal fluid at the site of UGF
  12. Ensure high fluid intake so as to reduce the risk of infection
  13. In 3 months allow general condition to improve and local tissues are likely to be free from infectionFurther delay likely to produce more fibrosis
  14. Perineal and vulval dermatitis and local infection treated with zinc oxide ointment, glycerine, vaselineUrinary infection should be treated
  15. JACK KNIFE- PATIENT is in prone position with hips abducted and flexed and table jack knifed
  16. JACK KNIFE- PATIENT is in prone position with hips abducted and flexed and table jack knifed
  17. Flap-splitting closure of a simple vesicovaginalfistula. A: Ureters have been catheterized. An incision through the vaginal epithelium is made circumferentially around the fistula. B: The vaginal epithelium is widely mobilized from the bladder. The scarred fistula tract should be excised. C: A continuous (or interrupted) delayed-absorbable suture inverts the mucosa into the bladder. D: A second suture line is placed in the musculofascial layer to reinforce the first. Vaginal epithelium is trimmed and approximated.
  18. It is an excellent procedure for correcting small posthysterectomy fistulae at the vaginal apex.The Latzko operation is a partial colpocleisis involving the upper 2 to 3 cm of vagina that surrounds the fistulaSuitable for fistula which is small and high in vaginaLatzko technique for a closure of a simple posthysterectomyvesicovaginalfistula. A: A circumferential incision is made around the fistula. The fistula is not excised. B: The vaginal epithelium is mobilized approximately 2 cm from the fistula. C: Delayed-absorbable interrupted mattress sutures are placed parallel to the edge of the fistula tract to invert it into the bladder. D: One or two additional rows of suture approximate the musculofascial layer of the bladder. E: The vaginal epithelium is closed transversely with interrupted delayed-absorbable sutures
  19. Transvesical – fixed and high fistula in vaultTransperitoneal- vesicouterine fistula, ureteric fistulaCombined- is used when fistula margin are close to the ureteral orifices.
  20. Rectum is protected by peritoneum of POD in upper 1/3rd, by perineal body in lower 1/3rd , and by sacral hollow in middle 1/3rd. Hence if the sacrum is flat, during obstructed labour—the compression effect produces pressure necrosis, sloughing and fistula
  21. Heavy irradiation of any type causes ishchemic necrosis of bowel and lead to fistula with stricture 3months to several years after treatment.Malignant rectovaginal fistula nearly always means primary disease in the bowel.Rectum may be opened during TAH or any operation which volve puncture, incision or dissection on the posteriod vaginal wall and fornix. If injury not identified and repaired --. Usually results in fistula
  22. Proctosigmoidoscopic examination for integrity of intestinal mucosa
  23. Methylene blue is inserted into rectum which can be seen coming out through vagina.Contrast studies
  24. Contrast studies are used to define sigmoidovaginal fistula and fistula with primary bowel diseaseProctosigmoidoscopy is done to ensure that the integrity of intestinal mucosa is normal
  25. involves a circular incision about the fistulous opening (Fig. 40.14). With traction on the vaginal wall and countertraction applied to the edge of the fistulous tract, the vagina is separated from the underlying rectal wall with sharp dissection, and this proceeds circumferentially (Fig. 40.15). This wide mobilization permits later approximation of the fresh injury free of tensionthe entire fistulous tract is excised to include a small rim of the rectal mucosa (Fig. 40.16), converting the fistula to a fresh injury
  26. With the surgeon&apos;s nondominant index finger lifting and supporting the anterior rectal wall, the initial sutures are placed extramucosally, including a portion of the muscularis and submucosainitial suture line begins and is extended a full 5 to 8 mm above and below the site of the fistulous tract to assure complete closure. A second layer P.1018(Fig. 40.18) begins 5 mm above the previously closed suture line and extends 5 mm distal to the fistulous closure, inverting the initial suture line into the rectum, and no sutures are located within the rectal lumen.