VVF

Prof J. Kasule, FRCS, FRCOG

Department of Obstetrics and
Gynaecology
University of Zimbabwe
 INTRODUCTION
• Foresee the foreseeable Complications of
• Prevent the preventable pregnancy, labour

Reduce mortality and morbidity: mother and baby

Example of success story: VVF in Zimbabwe

Cases
Seen
At Harare
Hospital

1980 1986 1988 1992 1994

Year
 VVF IN ZIMBABWE
120
Referral
Incidence
100
%

80

60 HH
Gok
40 we

20

0
1980 1990 1999

Years
VVF

Types
•VVF
•RVF
•UVF
 CAUSES OF VVF
(A) Congenital – Malformation of the cloaca
(B) Acquired
1. Obstructed labour = accounts for 95%
2. Obstetric injuries
- Forceps
- Vacuum
3. Operative
- Caesarean section
- TAH
- Vaginal operations: colporrhaphy- anterior, posterior
4. Complication of disease
- Pelvic abscess
- Diverticulitis
- Pyosalpinx
- TB
- Carcinoma of cervix
5. Radiotherapy
 Pathophysiology
• Ischaemic necrosis due to pressure results in
sloughing of bladder or ureter or rectum leakage is
delayed 3-7 days
• Direct trauma – at c/s or operation the leakage is
immediate
• Irradiation injury ischaemic necrosis

Clinical features
• Continuous leakage. Distress to woman – 2⁰
amenorrhoea
• Small defects are difficult to diagnose three swab test
 Management
(A) General Health
- Bloods – FBC, U & Es, Urine culture
- High protein diet
- Correct anaemia
- Antibiotics for sepsis
(B) If recent VVF wait for at least 3/12 before repair. No catheters
(C) Operative procedure
- Abdominal approach for high VVF
- Vaginal approach – for most of them
- EUA – identify the fistula
- Dissect all round the fistula to remove fibrous tissue
- Dissect vaginal mucosa from the bladder
- Mobilise bladder as much as possible
- Repair the bladder in 2 layers
- Repair vaginal mucosa
- Continuous bladder drainage for 14 days
 Management (cont.)
(D) Complications
- Those which occur with any pelvic operation
- Specific to VVF repair
- Vaginal stenosis / shortening
- stress incontinence due to shortening of urethra
 Prevention of VVF
1. Health Education
- Increase awareness of the dangers of obstructed labour to:
- Population
- Health workers – village level – tertiary
- Traditional birth attendants
2. Improve communication
- Electronic – telephone, radio telephone
- Roads
- Make ambulances available
- Channels of referral – clear
3. Widespread adherence to the use of the partogram
- In all centres
- Book primigravid in hospitals with facilities for caesarean section
- Use of waiting facilities for high risk mothers
4. In health institution
- Avoid prolonged labour
 Utero–vaginal prolapse
Definition: General
1st degree
2nd degree
Complete – (procidentia)
Aetiology:
1. 90% of the cases occur in women who have given birth
- softening of pelvic tissues as a result of pregnancy
- stretching during pregnancy
- premature bearing down
- trauma during delivery
2. Racial – genetic factors – more common in caucasian races
3. Hormonal factors; More common after menopause
 Management
Good history
- Are the symptoms due to prolapse
 Sensation of weight in front passage
 Difficulty in micturition
 Backache
 Coexisting stress incontinence
 Enquire about general health – cough
Examination
General
 CVS
 RS
 Examination
PA: exclude any abdominal masses
Pelvic examination:
Test for incontinence of urine
 Establish degree of prolapse:
Existence of Cystocele
Rectocele
Enterocele
 Specific Treatment
(A) Non surgical – poor surgical risks, improve general
health, Ring pessary
(B) Surgical
1. Vaginal hysterectomy and pelvic floor repair
2. Anterior colporrhaphy and amputation of cervix
(Manchester repair / Fothergill)
3. Posterior colporrhaphy
Anterior Colporrhaphy
 Complications of vaginal operations
1. During operation
- haemorrhage
- Injury to adjacent tissues
2. Post operative collapse
3. Retention of urine
4. Infection; locally, UTI
5. Thromboembolism
6. Vaginal stenosis
Stress Incontinence
 Stress Incontinence (cont.)
Assess
• Good history
• Examination
• Investigation
• Preoperative preparation
• Operations
- Anterior colporrhaphy and buttressing of UV angle
- Marshall-M operation
- Aldridge sling
• Post operative complications