Vesicovaginal fistula evaluation

2. Introduction

 Vesicovaginal fistula (VVF) are the most common
acquired fistula of the urinary tract.
 Descriptions of vesicovaginal fistulas have been
well documented since ancient times, although early
attempts at repair met with little success.
 In 1852, Sims published his method for the surgical
treatment of VVF using a transvaginal approach,
followed by Trendelenburg in 1888, who
successfully performed the transabdominal VVF
repair.

3. Objectives of VVF assesment
Objectives of evaluation of Vesicovaginal fistula is to determine
certain characters of fistula including:
 Site
 Size
 Number
 Fibrosis and Scarring
 Recurrence
 Involvement of ureteric orifices
 Involvement of sphincteric mechanism
 Associated vagino-rectal fistula.

4. Algorhythm for
management of VVF


5. Evaluation
 Evaluation of VVF consists of:
 History
 General and Genital Examination
 3 Swab test (Gauze test)
 Radiological evaluation
 Cystoscopic evaluation

6. History
Vesicovaginal fistula is presented usually
with Immediate or delayed onset of urinary
leakage from the vagina post-operatively or
after radiation (may take months or even
years).
Patients may also complain of recurrent
cystitis, perineal skin irritation due to
constant wetness, vaginal fungal infections.
When a large VVF is present, patients may
not void at all with continuous leakage.
VVF must be distinguished from urinary
incontinence.

7. History
History aims at gathering data about:
Etiology:
 Previous history of gynaecological surgery
(e.g, Vaginal or abdominal hysterectomy )
 Previous history of pelvic radiotherapy
 Prevoius history of prolonged labour or
trauma during childbirth
Time of occurrence
Previous Attempts of repair.
Co-morbidities.

8. History
If previous delivery is a suspected
cause of VVF, detailed obstetric history
should be gathered:
 Parity
 Caesarean sections and Vaginal deliveries
 If problem occurred after delivery
 Time in labour? .....days
 Where was delivery? Home , Hospital, on
way to hospital, other
 Did the baby live?

9. History
Presence of urine leakage
Timing of urine leakage
 When walking
 When lying down
 Continuous leak
 Stress incontinence ( e.g. cough)
 With urgency and frequency
any leakage of feces: Solid or liquid?
any gas leakage
previous operation for a fistula
Date of most recent fistula repair Operation
Number of previous repair attempts

10. History
 Genital irritation and / or crustations
 any trouble walking or “footdrop”
 Menstural history: menstruating or not?
 If not: for how long ?
 current marital status ? Married /Separated
/Divorced /Widowed
 sexual intercourse
 Age 1 st married
 Age 1 st delivery

11. Genital Examination
 Palpate anterior and posterior wall
 Use speculum.
 Vaginal examination may demonstrate
the VVF, if large (the examining finger
can reach inside the bladder).

12. Genital Examination
 Foot Drop( /5): Right –sided / Left – sided
 Number of Fistulas :
 Type of fistula: Utero –vesical ,Cervico- vesical ,Mid
– vaginal ,Bladder Neck ,Urethro – vaginal ,Recto-
vaginal
 Location: urethra / UV junction / trigone / above
trigone
 Proximity to cervix: -- cm
 Length of urethra: -- cm

13. Genital Examination
 Quality of tissue: good / moderate scarring / severe
scarring /inflamed
 Mobility of tissue: good / some mobility / poor
mobility / fixed
 Bladder Capacity ( measure (meatus to bladder wall
) minus ( meatus to foley balloon ) : <3cm (minimal )
3-5 (small ) / 6-8 ( moderate /8-10(normal ) />10( large)
 Vulva: Encrustation / Ulceration
 FGC: clitoris absent /labia absent / clitoris and labia
absent
 Introitus: Normal / tight /gaping or wide
 Fibrosis /scar: mild, moderate ,severe, fixed to bone

14. Genital Examination
 Urethra: Normal/ fistula / Absent or completely
open / Separate from bladder :
 Urethral fistula cm
 Separation from bladder -----------cm
 Urethral meatus : Normal /absent / not connected to
urethra
 Vagina : Normal / fistula
 Vaginal fistula -----cm

15. Genital Examination
 Involvement of bladder neck
 Cervix: Normal /Lacerated/ fistula near cervix
 Uterus: Normal / large /not felt
 Ovaries: Felt/no felt
 Rectum: Normal / fistula
 Rectal fistula ------cm
 Sphincter tear: No /partial / Total
 Type of pelvis : Android /Gynecoid/
Anthropoid / platellypoid / Other

16. Genital Examination
 Impression A:
 Type I:Not involving closing mechanism
 Type III: Involving closing mechanism
 Type III: Miscellaneous : ureter and other exceptional
 Impression B:
 A:Without urethral involvement
 B:With urethral involvement
 Not circumferential
 Circumferential
 Size : <2, 2-3, 4-5, >6
 Scarring : Mild , Moderate ,severe
 #previous Attempts:
 Plan

17. 3 swab test (Vaginal Gauze test)
Three separate sponge swabs are placed into the
vagina one above the other.
The bladder is then filled with a coloured agent
such as methylene blue, and the swabs are
removed after 10 minutes
©

18. Results of 3 swab test
1. Discoloration of topmost swab
is caused by vesico-vaginal
fistula.
2. uppermost swab wetting but not
discolouration suggest
ureterovaginal fistula
3. Discolouration of only the
lowest swab suggests low
urethral fistula or from back flow
into the introitus.
©

19. Radiological Evaluation
 Cystogram  of limited value.
 IVP  only if uretero-vaginal fistula is suspected.

20. Cystoscopic Evaluation
Cystoscopy is very valuable in the
assesment of VVF to determine:
Site of fistulae
Number of fistulae
Involvement of ureteric orifices

21. Cystoscopic evaluation- Site of VVF
Site of the VVF may be:
1. Supratrigonal
2. Trigonal
3. Involving bladder neck
4. Involving urethra

22. Cystoscopic evaluation- Site of VVF
The bigger the size the more the fistula is
complicated
Larger fistulae  worse outcome  use
tissue interpositioning
Large fistulae repair  contracted bladder.
Cut-off size  4cm ??

23. Cystoscopic evaluation- Number
of VVFs and other factors
 All fistulae should recognized because missing a
fistulae means failure.
Other Factors
 Scarring  worse outcome use tissue
interpositioning
 Recurrence  worse outcome  use tissue
interpositioning
 Involvement of ureteric orifices reimplantation
 Involvement of sphincteric mechanism  anti-
incontinence procedure later.
 Associated Vagino-rectal fistulae  should be
repaired simultaneously ± colostomy.