CASE STUDY ON:

Vesico-vaginal Fistula

Submitted by :
Anisha Shrestha
Roll no. 2
BSN 3rd year 5th batch
 CONTENT
1. Objectives
2. Rationale for case selection
3. Patient’s profile:
• Demographic data
• History of patient
• Physical examination
4. Disease condition ( Vesicovaginal Fistula)
– Introduction
– Epidemiology
– Causes
– Types
 – Clinical manifestation
– Diagnostic evaluation
– Complications
– Management
5.Nursing management
– Application of theory
– Nursing care plan
6. Progress report
7. Stress and diversion therapy
8. Health teaching and Discharge teaching
9. Learning from experiences
10. Summary
11. References
 OBJECTIVES
• General objectives :
 To gain comprehensive knowledge about the disease and
to provide holistic care to the patient.

 To fulfill the need of our Obstetric Nursing Practicum in

developing and advancing our knowledge and skill in
clinical setting
• Specific objective :
• To develop the skill of history taking especially menstrual and
obstetric history, general examination and gynecological
examination.
• To recognize various gynecological problems and their
appropriate management.
• To identify the various investigation and special treatment
modalities used in gynecological problems
• To conduct appropriate interventions in care of patient and
family with gynecological problem using nursing process.
• To demonstrate skills which provide comfort and recovery of
the patient.
• To develop the skill of communication and counseling.
• To provide health teaching according to the need of the patient
 Rationale for Case Selection
• In our clinical posting to Scheer Memorial Adventist Hospital for
1 month and 3 weeks , I got a chance to deal with various
disorders seen in women in practical basis.
Among the many conditions admitted in the hospital ,I chose
Vesico-vaginal Fistula for my case study because:
 VVF is abnormal fistula tract extending between the bladder and
the vagina that allows the continuous involuntary discharge of
urine into the vaginal vault.
 There are still no firm facts about the numbers of women with
fistulae but a team performing an obstetric fistula needs
assessment has estimated a prevalence of 4000–5000, with an
incidence of 200–400 annually.
(Heywood .S , 2012)
 Demographic Data
• Name: Jessica Rai
• Bed no: 2
• Ward: Gynaecological ward
• Age/sex : 32 years/ Female
• Address: Gwarko , lalitpur
• Ethnic group: Janajati
• Religion: Hinduism
• Nationality: Nepali
• Diagnosis: Vesico-vaginal Fistula
• Marital status: Married
• Education: completed high school
• Occupation: Housewife
• Height: 165 cm
• Weight: 70kg
• Date of admission: 2077-08-10
• Date of interview:2077-08-10
• Informant: Patient herself
• Attending doctor: Dr. Sudeep Maharjan
 History taking:

1. Chief complains of the patient:

• Dribbling of urine * 20 days
• Burning sensation *7 days
• Ammonical smell urine
2.History of present illness:

According to patient, she had difficulty forcep

delivery one month ago and was apparently well but
after, 20 days dribbling of urine was experienced and
few days later she also experienced burning sensation with
ammonical smell.
She came for checkup and was examined in the outpatient
department , dribbling of urine was noted on speculum
examination and after diagnosis and advice by the doctor ,
she was admitted to the gynaecological ward on the same
day at 2 pm with diagnosis Vesico-vaginal Fistula .
3.History of past illness:
• Medical history :There is no history of any major
illness.
• Previous hospitalization : during the time of
pregnancy
4) Menstrual history
Age of menarche: 15 years
• Regulation of cycle: 3 months gap in starting of
menstruation, then it became normal.
• Interval of menstrual cycle: 28-30 days
• Length and amount of bleeding: 3-4 days
• Amount : Moderate (2-3 pads per day)
• Pain (Dysmenorrhea) : Mild pain during menstruation.
5) Obstetrical history:
• Married for 5 years
• Gravid: .G1
• Para: P1
• No. of children / sex : 1 / female
• Type of delivery : Forcep delivery
• Place of delivery : Paropakar Maternity and Women’s
Hospital (PMWH) , Thapathali
• Complication during pregnancy and labor : Prolonged
labor
 6) Socio-economic condition

• Number of family member: 5 members

• Type of house: Joint family
• Income of the family is enough for fulfilling basic
needs so economic condition of the family is moderate
.
7) History of any allergies:

• There is no any known history of drug allergies.

• No history of food allergies.
• No any environmental or other allergies.

8) History of previous hospitalization and chronic

illness:
There is no any history of previous hospitalization
and chronic illness as information given by patient
herself.
9) Family History

• Mother’s family:
No any history of diseases like High blood pressure,
Diabetes, Cancer, Blood disorder, Cardiovascular
problems, Arthritis/Gout, Asthma, Tuberculosis, e.t.c. in
the family.

• Father’s family:
No any history of diseases like High blood pressure,
Diabetes, Cancer, Blood disorder, Cardiovascular
problems, Arthritis/Gout, Asthma, Tuberculosis, e.t.c. in
the family.
Family Tree
 Maternal Paternal

55 yrs 58 yrs 54 yrs

51 yrs

32 yrs 33 yrs 31 yrs 29 yrs

33 yrs

1 mnth
Index :

- Male

- Female

- Patient
 9. Nutritional History:
• Diet: Non- vegetarian
• Dietary pattern before present illness: Normal diet
10. Recreational habit:
She likes to listen to music, watch television, walk in the
evening during her free time.

11.Health practices:
The patient and the family follows modern allopathic
health practice.
 Physical Examination
1.Vital signs: 
• Temperature: 98.8 o F
• Pulse: 74 beats/min
• Respiration: 22 /min
• Blood Pressure: 120/80 mm of Hg
• SPO2: 98% in room atmosphere
2. Anthropometric measurement:
• Weight: 70kg
• Height: 165 cm = 1.65 m
• Body mass index(BMI): Weight in kg
(height in m)2
=25.71 (over weight)
 ABNORMAL FINDINGS
• Patient look anxious and gloomy.
• All the vital signs of the patient were normal.
• Lips were dry and cracks were present.
• Leakage of urine and excoriation of vulva was
present.
• Ammonical smell was present
• Pain around the vagina was informed by the patient.
DISEASE CONDITION

Vesico-vaginal Fistula
 Definition
 The communication between the bladder and the vagina
and the urine escapes into the vagina causing the
incontinence is called vesico -vaginal fistula.

 VVF is abnormal fistula tract extending between the

bladder and the vagina that allows the continuous
involuntary discharge of urine into the vaginal vault.

 It is the commonest type of genito-urinary fistula.

 Epidemiology
• In Nepal , Since 2011 the United Nations Population
Fund has coordinated a campaign with government
health services and fistula treatment centres. There are
still no firm facts about the numbers of women with
fistulae but a team performing an obstetric fistula needs
assessment has estimated a prevalence of 4000–5000,
with an incidence of 200–400 annually.
(Heywood .S , 2012)
• An incidence of 1-2 per 1000 deliveries has been
estimated worldwide, with an annual incidence of upto
50,000 to 1,00,000.
(Tayade . S , 2012)
 Incidence
Background : Vesico vaginal fistula is an abnormal fistula tract
extending between the bladder and the vagina that allows continuous
discharge of urine into the vaginal vault.
Objective : To review the outcome of vesicovaginal fistula in
Nigeria.
Methods : Retrospective study was done from 1981 to 2005 in the
University of Nigeria Teaching Hospital, South West.
Result : Total 476 cases were found of vesico-vaginal fistula in which
majority of VVfs were of obstetric origin , resulting from vaginal
delivery (n=330),caesarean section(n=35),caesarean hysterectomy
(n=26), and instrumental delivery(n=21)and remaining 64 resulted
from pelvic surgery , malignancy , and radiotherapy treatment.
( Obi ,et al., 2009)
 Causes
• Congenital : Rare
• Obstetrical
In the developing countries, the commonest cause is
obstetrical and constitutes about 80-90% of cases . The
fistula may be due to ischemia or following trauma.
 Ischemic
It results from prolonged compression effect on the bladder
base between the head and symphysis pubis in obstructed
labor.
 Traumatic
This maybe caused by;
• Instrumental vaginal delivery such as destructive
operations or forceps delivery.
• Abdominal operations such as hysterectomy for rupture
uterus or cesarean section. The injury may be direct or
ischemic.
• This type of direct traumatic fistula usually follows soon
after delivery.

• My patient had instrumental vaginal delivery that is

forcep delivery.
• Gynaecological
- Surgical trauma: bladder may be injured during
abdominal surgery. e.g. Hysterectomy
-Traumatic: fall on a pointed object , criminal abortion ,
fracture of pelvic bone.
-Malignancy: as advanced carcinoma of cervix or of a
bladder , or vagina may produce fistula by direct spread.
-Radiation :There may be ischemic necrosis due to
radiation (overdose or mal-application for a longer period
of time)effect, when the carcinoma cervix is treated by
radiation.
-Infection: such as tuberculosis of bladder, pelvic abscess
may open into bladder and vagina. 
 Types of VVF
The types of VVF depends upon the site of the fistula
, it may be:-
1) Juxta-cervical (close to the cervix):-
 The communication is between the supratrigonal
region of the bladder and the vagina.

2) Mid vaginal:-
 The communication is between the base (trigone)
of the bladder and the vagina.
3) Juxta-urethral:-
 The communication is between the neck of the
bladder and vagina (may involve the upper
urethra as well).
 Clinical Features
According to book According to my patient
• Continuous leakage of urine • Present
occurs through the vagina
during the day as well as the
night (true incontinence),
which is the characteristic
feature.

• No urge to pass urine. • Present

• The patient may pass urine • Present
normally too and also leak
urine through the vagina and
sometimes only in certain
positions.

• The vaginal skin appears red • Present

or inflammed and
excoriated.

• The smell of urine may be • Present (ammonical

noted. smell)
 Diagnosis
• According to the book • According to my
patient

• History taking:- • Done

Historical information
regarding obstetric deliveries ,
prior surgery , previous
management of fistula and
treatment of malignancy.
• Physical examination • Done
• Dye test: A speculum is introduced and the • Not done
anterior vaginal wall is swabbed dry.
When the methylene blue solution is
introduced into the bladder by a catheter,
doctor will ask to cough or bear down , if
vaginal fistula then the dye will be seen
coming out through the opening.

• Speculum examination: • Done ( on

A sims’s speculum in sims’ position gives the outpatient
information about the size, site and number of department)
fistula. A full vaginal inspection is essential.
• Three swab test: The three • Not done
swab are placed in the vagina
one at vault , one at the middle
and one just above introitus.
The methylene blue is instilled
in the bladder through a rubber
catheter and the patients is
asked to walk about 5 min . She
is then asked to lie down and
the swab are removed for
inspection.
• Cystoscopy if confusion in diagnosis • Not done
• Urine test • Done
• X-rays: • Not done
 Retrograde pyelogram : dye is
injected through bladder into ureters
and can show whether there is
leakage between ureter and vagina.
 Fistulogram : X ray image of fistula
and show whether one or many
fistula and if other pelvic organs are
involved.
Cystoscopy
 Types of repair of VVF
• There are many techniques of repair which include:
1. The Vaginal approach
2. The Laparoscopic approach
3. Electrocautery
4. Fibrin glue
5. Endoscopic closure using fibrin glue with or without
adding bovine collagen.
• My patient did not have any kind of surgery as the
ideal time for surgery is usually after 3 months
following delivery.
1.Vaginal Approach
Most of the fistulas can be repaired with ease and
good exposure through this approach.
The vaginal approach avoids bowel manipulation ,
reducing operative morbidity , particularly in patients
with radiation – associated fistulas.

Vaginal wall is dissected and separated from bladder wall.

Bladder wall is repaired protecting ureteric injury or
suturing.
 Latzko technique
It is used to repair a VVF that develops following total
hysterectomy operation.
• Principle of this surgery is to produce partial colpocleisis
(destruction of vagina around the fistula). This procedure
is suitable for a fistula which is small and high in the
vagina.

 Flap splitting method

• Excision(minimal) of the scar tissue round the margins
using perfect asepsis.
• Mobilization of the bladder wall from the vagina.
• Suturing the bladder wall without tension in two layers.
 Saucerisation ( Edge paring and
suturing)
• Exposing the fistula with Sims’ speculum and after
paring the margins , sutured the fistula with silver wire.
• Saucerisation is the closure of a small fistula using
interrupted stitches without dissection of bladder from
the vagina.
• This may be employed in a very small fistula using vicryl
(2-0).
2. Laparoscopic approach
• The fistula can be repaired with greater detail and
complete visualization by utilizing the minimally invasive
approach .
• The viewing telescope is passed through the port and
attached the video camera. Appropriate forceps are passed
through the ports and dissection is performed to separate
bladder from vagina.
• The bladder mucosa adjacent to the fistula is excised and
repaired. The vaginal defect is repaired separately. The
bladder drainage is drained suprapubicaly or uretharly
temporarily.
3.Electrocautery and endoscopic closure using Fibrin
Glue
• This is minor most surgery for fistula repair. It can be
used to repair smaller VVF. The electrical destruction of
the fistula leads to closure and healing of the fistulous
tract. Fibrin glue can be used with this procedure to give
better results.
 Complication
1. Recurrent fistula formation
2. Vaginal stenosis
3. Reduced bladder capacity
4. Irritative lower urinary tract symptoms
 Management
According to book According to my
patient
 Immediate management
• Insert an indwelling catheter • Indwelling catheter
and start continously closed was inserted to my
drainage. patient.
• Ensure high fluid intake. • Hydration was
maintained by fluid
intake .
• Mobilize her early , always
keeping the bag below her
bladder.
• Mobilization was
encouraged to
patient by keeping
her bag below the
bladder.

• After 7-10 days, examine her • It was examined on

anterior vaginal wall in sim’s the first day of
position with speculum. admission at
(If her bladder is still bruised or outpatient
necrotic ,leave her catheter in and department.
remove only when healthy tissue
is seen in next examination. )
Nursing management
 Application of nursing theory
I applied Virginia Henderson’s Need nursing theory.
The theory focuses on the importance of increasing the
patient's independence to hasten their progress in the
hospital. She has identified 14 basic needs of the patient
which comprises the components of nursing care.
I assessed my patient according to the components given
by the theory while providing nursing care to my patient.
S ACCORDING TO ACCORDING TO MY
N. BOOK PATIENT
1. Breathe Normally My patient was able to breathe
normally.

2. Eat and drink adequately Her diet was normal . She eats and
drinks adequately.

3. Eliminate body wastes My patient had normal bowel

habit but had impaired bladder.

4. Move and maintain My patient was not able to move

desirable postures. and maintain desirable postures
due to insertion of catheter.
5. Sleep and rest My patient was not able to rest
and sleep properly due to pain.
6. Select suitable clothing. That My patient was able to dress
is dress and undress and undress appropriately.
appropriately.
7. Maintain body temperature Her body temperature was
within normal range by within normal range.
adjusting clothing and
modifying the environment
8. Keep the body clean and well My patient’s body was clean
groomed and protect the and well groomed but due to the
integument. continous leaking of urine there
was ammonical smell.
9. Avoid dangers in the My patient was able to avoid
environment and avoid injuring dangers in the environment and
others. avoid injuring others.
10. Communicate with others in My patient was able to
expressing emotions, needs, communicate with others and
fears or opinions seems anxious.
11. Worship according to ones She follows Hinduism. So she
faith. goes to temple and worship
accordingly.
12. Work in such a way that there My patient was able to work in
is a sense of accomplishment. such a way that there is a sense of
accomplishment.

13. Play or participate in various My patient was able to participate

forms of recreation. in recreational activities.

14. Learn, discover, or satisfy the She used to ask question

curiosity that leads to normal regarding disease condition and
development and health and fulfill her curiosity.
use the available health
facilities.
 Assessment
• Proper history taking; including history of present, past
illness, dietary history along with family history.
• Head to toe physical examination was done to find out
signs and symptoms of the disease condition.
• Assess the general condition of the patient.
• Monitor the vital signs of the patient.
• Assess the nutritional status of the patient.
• Assess bowel bladder pattern and input output chart of the
patient.
• Assess the coping pattern and effect of hospitalization on
normal developmental task of the patient.
 Diagnosis

• Acute pain related to vesicovaginal fistula as evidenced by

patient’s vebalization.
• Anxiety related to hospitalization as evidenced by facial
expressions.
• Disturbed sleep pattern related to psychological stress as
evidenced by interrupted sleep.
• Risk of ascending infection related to catheterization.
• Low self esteem related to bad odor as evidenced
by nervousness.
Nursing Care Plan
Assessme Diagnosis Goal Planning Impleme Rationale Evaluatio
nt ntation n

Objective Acute -To -To assess -The -To find My goal

data: pain relieve the general out the was
-The related to pain . general condition current fulfilled as
patient vesicovagi condition of the condition the patient
was nal fistula of the patient of the was
restless as patient. was patient. relaxed
and evidenced assessed. and didn’t
uncomfort by complain
able and patient’s -To place -The -It about
verbally vebalizati the patient patient provides having
complaint on. in the was comfort pain.
about comfortab placed in and eases
having le position a pain
pain. comfortab
le
position.
-To encourage the patient - -The patient was -To alleviate pain by non-
to ventilate her feelings. encouraged to share her pharmacological
feelings. measures.

-To involve patient in -Patient was involved in

diversion activities like diversion activities like -It refocuses the attention
talking and listening talking and listening from the pain.
music. music.

-Administer the analgesics -Paracetamol was

as prescribed by doctor. administered as prescribed -It suppressed the pain
by doctor. receptors in the brain.
Assessme Diagnosis Goal Planning Impleme Rationale Evaluat
nt ntation ion

Objective Anxiety To reduce -To assess -The level -To find My set
data: related to the the level of anxiety reason for goal
patients hospitaliz anxiety of anxiety. was anxiety. was met
seem ation as with 1 -2 assessed. as my
depressed, evidenced days. patient
sad , by facial was also
anxious. expressio -To -Quiet -Reduction talking
ns. provide and of external with
quite and peaceful stimuli other
peaceful environm helps to patients
environm ent was promote and
ent. provided relaxation sharing
about
her
disease
conditio
n.
-To build trustful -Trustful relation was built -It helps to trust and share
relationship with patient by talking with her in a feelings .
and visitor. polite manner and
explaining her about
disease condition.

-To provide diversional •-Diversional therapy was •-It helps to divert mind
therapy to the patient. provided by suggesting and minimize stress and
her listening to music and anxiety.
talking with other patients.
Assess Diagnosi Goal Planning Impleme Rationale Evaluati
ment s ntation on

Objectiv Disturbed Patient -To assess -Patients -To identify My goal

e data: sleep will be patient sleep sleep and establish was
Patient pattern able to pattern and pattern plan of care. achieved
seemed related to establish changes and as
lethargi psycholo sound ,awakenings changes patient
c due to gical sleep and was had been
lack of stress as pattern. frequency. assessed. able to
proper evidenced establish
sleep. by -To monitor -Patients -To identify sound
interrupte for complain causative sleep
d sleep. complaints of pain factors of pattern.
of pain and and frequent
discomfort discomfor awakenings
t were help facilitate
monitore change in
d. sleep pattern.
-To help patients in -Patient was helped in -Relaxation techniques
relaxation techniques , relaxation techniques helps to promote sleep.
guided imagery , and ,guided imagery,and
muscle relaxation. muscle relaxation.

-To provide warm -Warm drinks and extra -Promote comfort and
drinks ,extra cover prior to cover provided prior to relaxation prior to sleep
bedtime bedtime
 Preventive measures:-
 Adequate antenatal care is to be extended up to screen out
at risk.
 Early detection and ideal approach in the method of
delivery in relieving the obstruction.
 Availability of emergency obstetric care services like
cesarean section in case of obstructive labor.
 Care to be taken to avoid injury to the bladder during
pelvic surgery (obstetrical or gynaecology)
 Creating community awareness through culturally
sensitive , information , education and communication for
behavioural change.
 Progress report:
• 2077-08-10
General condition of the patient looked lethargic.
However she was well oriented. She was feeling dizziness.
Indwelling catheter was inserted that day . I also gave her
information about catheter care.
• 2077-8-11
Patient looked gloomy and anxious. However, she was
well-oriented. I maintained Interpersonal relationship with
the patient and took history from the patient and family.
Physical examination was performed and I explained the
normal and abnormal findings to the patient.
• 2077-8-12
The patient was not irritated, well oriented and looked
cheerful and co-operative. Her vital signs were normal.
Patient was encouraged to ambulate by keeping catheter
bag below the bladder. High fluid intake was encouraged.
She was also educated about the hand and menstrual
hygiene.
 Stress and Diversional Therapy
To minimize the stress of patient and patient’s family
members due to different types of treatment procedures,
disease condition stress management has important role:
• Orientation was provided to family regarding ward
routine activities , rules and regulations , disease
condition and treatment procedure.
• Interaction with the patient was done in calm and polite
manner.
• Good interpersonal relationship was maintained.
• I advised her to listen to some music when bored.
• I also involved my patient in reading newspaper.
 Health teaching and discharge teaching
I provided informal health teaching to patient and her
family members so that her health condition gets improved. I
have health teaching on following topics:
a) Nutrition
• Nutrition is very important to the patient to improve the
normal functioning of the body. I encouraged the patient to
eat balanced diet and to intake fluid.
b) Rest and sleep
• Rest and sleep are very necessary for health. I encouraged
the patient to have adequate rest and sleep as it helps to
keep mind out of tension and provides rest to the body and
also relieving pain.
c) Personal hygiene
• It is very important for her to maintain her personal
hygiene . It prevents from infection of wound.
Therefore, I encouraged the patient to maintain personal
hygiene. I encouraged her to change her under garments
regularly and keep herself clean .
d) Exercise 
• Exercising is very important to maintain health as it
helps in keeping mind fresh and helps in good blood
circulation. I encouraged her to do exercise like deep
breathing and coughing exercise, meditation.
e)  Infection prevention
• The chances of infection are high after surgery. So I
advised the patient for proper wound care. I also taught
her about hand washing techniques. I made her alert
about all the possible signs of infection like fever, puss
formation, delayed wound healing. 
f)  Medication
• I explained her about the medication, that it should be
taken regularly and as per the doctor’s prescription. I
suggested her not to take over the counter drug.
g) Follow-up 
• Follow-up is necessary for the recovery process.
Therefore, I advised patient to visit on exact date and
time. If there is any problem seen, I advised her to visit
hospital immediately.
 Learning from experiences
• Case study is a very good approach to learn about the
disease and Nursing practice in depth.
• It is the suitable way of applying theory in practice in real
situation. Here are some points that I learnt from my case
study.
About the disease : I studied this disease indepth by the
resource available. I also obtained information from books,
internet , teachers , seniors and doctors. I learned about the
disease, it’s causes ,incidence , signs and symptoms and
management in detail.
About the patient :
I got the opportunity to gain knowledge about the history of
the patient including her health history, menstrual history, as
well as obstretical and surgical history. I got the opportunity to
compare the patient’s disease condition with the book picture
which helped me learn realistically.
About the family :
I also got the information about patient’s family background ,
socio cultural and educational background and their health
beliefs and concept about health and illness.
About nursing care:
I applied holistic nursing approach while proceeding nursing
care to patient. I also applied Virgina Henderson’s theory of
nursing while providing care to the patient. I also used the
NANDA’s diagnosis technique while using nursing process.
 Conclusion and Summary
Case presentation is a very important for us because it provides us
deep knowledge about the disease condition ,family history and
also develop our skill and attitude to implement the case in
optimal level.
During this posting, I got an opportunities to learn about disease
condition in detail and compare it with the patient. I got chance
to apply nursing theory and provide care according to nursing
process. I am satisfied with this presentation as it was beneficial
for me as well as my patient. I got a chance to develop my skill
and learn new technique to handle the situation .
So , I am very thankful to my dearest teacher for their continuous
guidance as well senior staffs, doctor , patients, patient’s family
for helping me to complete this study
 References
• Subedi .D (2020) ,Gynecology Nursing (1st editon) ,
pg – (153-165 ) , Kathmandu , Akshav Publication.
• Rai .L.(2015), Nursing Concepts theories and
principles (3rd edition).
• WebMD (2020) , Vaginal Fistula , retrieved from:
https://www.webmd.com/women/guide/what-is-a-vagi
nal-fistula
#
• S.N. Obi , B.C. Ozumba , A.K. Onyebuchi (2009),
retrieved from : https://
www.tandfonline.com/doi/abs/10.1080/014436108023
97686
• Heywood .S , (2012) , retrieved from :
https://www.rcog.org.uk/en/global-network/global-hea
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/
• Tayade.S , (2012) , retrieved from : https://
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OF_SUFFERING