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Comprehensive Guide to Evaluating Vesicovaginal Fistulas (VVF
1.
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.
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
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.