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UROGENITAL FISTULA
DR ABBAS MLANDULA MD
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Learning tasks
At the end of this session, students are
expected to be able to:
Outline epidemiology of urogenital fistula
Explain aetiology/risk factors of urogenital fistula
Explain clinical features of urogenital fistula
Establish diagnosis/ provisional and differential
diagnosis of urogenital fistula
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Learning tasks
Provide pre-referral treatment of urogenital
fistula
Provide control and preventive measures of
urogenital fistula
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Activity 1: Brainstorming

What is a fistula?
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Definition
A fistula: is an abnormal connection between
two or more epithelial surfaces.

Urogenital fistula: Abnormal communications

between urinary and genital organs.
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Epidemiology
Obstetric fistula affects about two million
women per year, almost all in developing
countries (particularly in Africa and the Indian
sub-continent).
Account for about 0.2 - 1% gynaecological
admission
The magnitude of the problem in Tanzania is
not well known due to under-reporting.
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Epidemiology...
Most of births take place at home (home
delivery), but it is estimated that the incidence
of obstetric fistula may be as high as 1200 new
cases per year
Obstetric cause is the commonest cause of
urogenital fistula in developing and account for
about 80 to 90 %
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Types of urogenital fistula

Bladder
Vesicovaginal - Abnormal communication
between the epithelium of the urinary bladder
and vagina, this is the commonest type of
obstetric fistulas.

Vesicouterine-Abnormal communication
between the epithelium of the urinary bladder
and uterus
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Types...
Bladder
Vesicocervical - Abnormal communication
between the epithelium of the urinary bladder
and cervix.

Vesicourethrovagina - Abnormal
communication between the epithelium of the
urinary bladder , urethra and vagina,
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Types.....
Ureter
Ureterovaginal - Abnormal communication
between the epithelium of the ureter and
vagina.
Ureterouterine - Abnormal communication
between the epithelium of the ureter and
uterus
Ureterocervical - Abnormal communication
between the epithelium of the ureter and
cervix
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Types....
Urethra
Urethrovaginal - Abnormal communication
between the epithelium of the urethra and
vagina.
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Causes
Acquired:
Obstetrical
Gynaecological
Accidental
Malignancy
Infenction
Radiotherapy

Congenital: very rare

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Causes
Obstetrical causes
Prolonged obstructed labour lead to compression of
soft tissues between head and brim of a narrow
pelvis.
 → ischaemia, pressure necrosis & sloughing of base
of the bladder.
 Urethra is also often involved.
Slough takes some days to separate
→ Incontinence develops 5-10 days after labour
Such fistulae are often surrounded by dense fibrosis
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Causes cont..
Obstetrical cause
• Instrumental delivery like forceps delivery
• Caesarean section
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Causes...
Gynaecological causes:
Bladder may be injured during vaginal
operation as anterior colporrhaphy or during
abdominal operations as hysterectomy
Urethra may be injured during vaginal
operation as anterior colporrhaphy
Ureter may be injured during during abdominal
operations as hysterectomy
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Causes cont…
Accident:
Road traffic accident-crush injuries to the
pelvis

Neoplastic fistula
Cancer of the cervix
Cancer of urinary bladder
Cancer of the vagina
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Causes cont…
Radiotherapy
Infections
Granulomatous infections, like TB
Syphilis
Schistosomiasis
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VESICOVAGINAL FISTULA
(The Commonest)
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Risk factors
Contracted maternal pelvis
Teenage pregnancies (pelvis is not yet matured)
Malnutrition in early childhood
Acquired contracted pelvis: accident/traumatic,
infections like polio or TB
Poor access and quality of emergency obstetric
care
Women may undergo prolonged labour, which
places stress on the reproductive organs, and may
contribute to fistula development
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Risk factors...
Low socioeconomic status
Women with VVF come almost exclusively from
poor families
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Activity 2: Brainstorming

What are clinical features of VVF?

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Clinical features
Incontinence of urine which normally develops
within one week after delivery
Symptoms of vulvitis/dermatitis:
Pruritus, burning pain due to continuous
discharge of urine.
Cystitis -Due to ascending infection from vulva
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Clinical features...
History of difficulty labour
Pelvic bone pain
Foot drop, unsteady gait
Psychologically depressed
Menstrual disturbance especially amenorrhea
Often mothers may end up with loss of babies
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Diagnosis
History of incontinence following labour or
operation.
Several days after labour necrotic obstetric
fistula
Immediately after difficult labour traumatic
fistula.
Palpation of anterior vaginal wall:
Large fistula Can be felt
Small fistulas cannot be felt, but surrounding
fibrosis is usually palpable
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Diagnosis...
Inspection of the anterior vaginal wall in Sims’
position or left with the use of Sims’ speculum.

For small and high fistula Dye test: Injection of

methylene blue into bladder by a catheter to
outline the fistula while anterior vaginal wall is
inspected by use of Sim’s speculum.
DD: uretrovaginal fistula
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Complications of obstetrical fistula

Physical complications:
Bladder prolapse
Wasting of pelvic muscles
Chemical vaginitis, UTI and sepsis
Partial or complete loss of the labia
minora/vagina, varying from loss of the anterior
vaginal wall to vagina stricture, circular stenosis
and even atresia
Anaemia (due to reduced intake of food)
Possible infertility
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Complications of obstetrical fistula...

Psychosocial complications:
Possible future inability to carry a child
Social and psychological pain that may lead to
suicidal ideation
Divorce
Family abandonment/isolation
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Management of Obstetric Fistula

Urethral catheterization - 40-60% of small
fistulas heal following four to six weeks of
catheterization
Plenty of fluid, minimum of 6-8L/day
Oral haematinics and high protein diet
Psychological support/counselling
Refer to hospital for VVF repair
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Prevention of Obstetric Fistula

Primary Prevention
Prevention of prolonged and obstructed labour
through Proper use of partogram in labour wards
Prevent teenage pregnancies through
reproductive health education and community
awareness and life skills - Family planning
Proper attendance at antenatal clinic which will
facilitate screening women at risk big babies,
contracted pelvis, encourage hospital delivery
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Prevention of Obstetric Fistula..

Encourage women to deliver at health care
facilities
Improve infrastructures:
Roads, communications (radio calls, phones and
ambulances for health facilities), ensure that
health facilities are accessible
Improve health facilities that will enable to
provide emergency obstetric care
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Prevention of Obstetric Fistula..

Ensure availability of trained health personnel
Economy
 Alleviate poverty
Socially; improve women’s decision making
power
Promotion of good health
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Prevention of Obstetric Fistula..

Secondary Prevention
Prevent fistula following obstructed labour by:
Early intervention for patients with obstructed
labour by doing caesarean section
Post delivery bladder catheterization
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Prevention of Obstetric Fistula..

Tertiary Prevention and Rehabilitation
When fistula has already occurred, prevention
is aimed at providing good environment for
either spontaneous healing or successful repair,
strategies include:
Early diagnosis of fistula
Measures for early treatment
Encourage training on fistula surgery
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Prevention of Obstetric Fistula..

Psychotherapy
Occupational therapy
Family planning
Encourage hospital delivery in
subsequent pregnancy
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Key points
The commonest cause of urogenital fistula is
obstetrical cause
Vesicovaginal fistula is a commonest urogenital
fistula
The range of physical and psychological problems
associated with obstetric fistula adversely affects
the quality of women’s lives in numerous ways.
Obstetric fistulae are preventable.
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Evaluation
1. What are the types of urogenital fistula?

2. what is the common cause of urogenital

fistula?

3. How will you prevent obstetric fistula?

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References
Shaw ’s Text books of Gynaecology- 16th
edition
D C Dutta’s Text books of Gynaecology- 6th
edtion