GENITOURINARY FISTULA

DR MAIRMON KHAN
LMO, UROLOGY DEPT BINUQ
Genitourinary Fistula

 Is an abnormal connection between urinary and genital tract with involuntary escape of
urine into the genital tract.

 2-7 million women affected worldwide

Types

Bladder Ureter Urethra

Vesicovaginal Ureterovaginal Uretherovaginal
Vesicouterine Ureterouterine
Vesicocervical Ureterocervical
Vesicourethrovaginal
Aetiology
Obstetrical causes

 ISCHEMIC NECROTIC OBSTETRIC FISTULA

Prolonged obstructed labour
In CPD and malpresentation, trigone of the bladder is nipped between
the presenting part and pubic symphysis that will result in Ischemic tissue
necrosis and sloughing that will in turn result in genitourinary fistula.

Slough take some days to separate thus incontinence develops 7-10 days
after delivery
Obstetrical causes

 TRAUMATIC FISTULA
Instrumental vaginal delivery
Include procedures which involve the use of forceps specially with the use
of keilland forceps
In LSCS
 At risk in patient with previous LSCS
 If bladder is caught in suture, can lead to ischemia and fistula formation
 Ligation of main uterine vessels incase of haemorrhage may result in ureter injury
 Rupture of scar of previous LSCS can implicate adherent bladder base

 In such direct traumatic injury, fistula and incontinence follows soon after delivery
Gynaecological causes

 OPERATIVE INJURY
Ureter - is at risk in total hysterectomy especially radical hysterectomy,
removal of broad ligament tumours
Risk of ureteral injury was seven times greater with laparoscopic
procedures than with open procedures

Urethra - is threatened during anterior colporraphy and sling operation

Malignancy

 Advanced carcinoma of cervix, vagina or bladder may produce fistula by direct spread
Radiotherapy

 Excessive, misapplied and even at times well applied irradiation for pelvic malignancy
especially carcinoma or cervix causes endarteritis obliterans resulting in Ischemic
necrosis and fistula

 Late complication – takes 1-2 years to produce such fistula

Infective

 Vaginal foreign bodies, forgotten and retained Pessaries

 Chronic granulomatous lesion such as genital tuberculosis, LGV, schistosomiasis,

actinomycosis – rare causes of fistula
Vesicovaginal fistula VVF

Is an abnormal communication between bladder and vagina the urine escapes into the
vagina resulting in true incontinence
VVF

 Most common acquired fistula of the urinary tract in the developing countries i.e ( > 75%).

 In the developed countries, the most common cause of VVF is injury to the bladder at the time of
gynaecological, urological or other pelvic surgery

 Whereas in under developing countries , the commonest cause of VVF are obstetrical causes

 1 - 4 per 1000 vaginal deliveries

 Affected individuals become permanent outcasts in society

Classification – according to the Site
of Fistula

1. HIGH FISTULA
2. MID VAGINAL FISTULA
3. LOW FISTULA
4. MASSIVE VAGINAL FISTULA
Classification

Simple VVF Complex VVF

 Fistula < 2-3 cm in size  Fistula > 3cm in size
 Single  Multiple
 Fistula near the cuff  Fistula distant from cuff
 Supratriagonal  Triagonal involvement
 No history of radiation or pelvic malignancy  History of radiotherapy or pelvic malignancy
 Vaginal length normal  Vaginal length is shortened
 Healthy tissue  Associated with scarring
 Good access  Previous unsuccessful repair attempts
Classification - according to size of
Fistula

1. Small fistula < 2 cm

2. Medium fistula 2 – 3 cm
3. Large fistula 4 – 5 cm
4. Extensive fistula > 6 cm
 Evaluation of VVF

 HISTORY
 EXAMINATION
 CONFIRMATION OF DIAGNOSIS
Evaluation of VVF - HISTORY

 Usually presents with continuous escape of urine per vaginum – true incontinence
(CLASSIC SYMPTOM)
 Patient got no urge to void urine
 Leakage of urine following surgical injury occurs from the first postoperative day
 Whereas in obstetric fistula symptoms take 7-14 days to appear
 Menouria – cyclical hematuria at the time of menstruation is present
 Pruritis vulvae, perineal skin irritation , fungal infection due to constant wetness
 HISTORY

 Age and socioeconomic status of woman ?

 Previous gynaecological surgery/ radiotherapy ?
 Previous history of prolonged labour/ trauma during childbirth ?
 Amount of leakage ?
 Any attempt of previous repair of fistula ?
 Evaluation of VVF – EXAMINATION

 General Examination
 Per Abdomen Examination – surgical scars
 Vulval inspection – escape of watery discharge per vaginam of ammoniacal smell is characteristic
Excoriation of the vulval skin
Varying degree of perineal tears may be present
 Per speculum Examination
Sim’ s position and Sim’ s speculum
Any pooling of fluid in vagina
Site, size and no of fistula
Assess quality of surrounding tissue – tissue mobility
Bladder mucosa may be visibly prolapsed through large fistula
Tiny fistula is evidenced by a puckered area of vaginal mucosa – when women coughs while lying in sims position
bubbles are seen coming through tiny fistula
Evaluation of VVF – CONFIRMATION
OF DX

 Dye test
 Three swab test/ Tampon test of Moir
 Double dye test
 Metal catheter
 Examination under anesthesia
Evaluation of VVF – CONFIRMATION
OF DX

LABORATORY STUDIES
 Vaginal vault fluid collection to rule out vaginitis
 Urine C/S
 Biopsy of fistula tract/ urine cytology if suspicious of malignancy
Evaluation of VVF – CONFIRMATION
OF DX

 IMAGING
A cystogram and or/ voiding cystourethrogram (VCUG) and an upper tract
study should be performed in patients being evaluated for VVF

Objectively determine the presence and location of fistula

VVFs are often best seen in the lateral position in which the bladder and
vagina are not superimposed
 Diagnostic Procedure - CYSTOSCOPY

 An endoscopic examination should be performed in patients where VVF is suspected

 Immature fistula may appear as areas of localised bullous edema without distinct Ostia
 Mature fistula may have smooth margins with variably sized ostia

 Cystourethroscopy  can confirm the presence of the fistula but also may reveal the size of the
tract, the presence of collateral fistulae, and the location of the ureteric orifices in relation to
the fistula. 
 Small fistulae, usually less than 3 to 4 mm in diameter, may be amenable to simple
fulguration, which can be performed at the time of cystoscopy.
Prevention - OBSTETRIC FUSTULA

 Primary prevention
Availability of family planning method services
Strategy to make motherhood safer should be followed
Good antenatal care
Watchful progress of labour
Trained birth attendants
Transportation and emergency obstetric car
 Secondary prevention
Insert an indwelling catheter and start continuous closed drainage
Early recognition of CPD and prevention of obstructed labour
LSCS only in indicated cases
Avoidance of difficult forceps
Prolonged catheter drainage in prolonged or obstructed labour
Prevention - SURGICAL FISTULA

 Adequate exposure during surgery

 Minimise bleeding and hematoma formation
 Dissection in correct planes
 Wide mobilisation of the bladder
 Intra op retrograde filling of bladder
Prevention – RADIATION FISTULA

 Proper dose and technique of irradiation

 Packing of vagina
 Midline block
 MANAGEMENT

The goal of treatment of VVF is rapid cessation of urinary leakage with return
of normal and complete urinary and genital function.
 CONSERVATIVE MANAGEMENT
 NON SURGICAL INTERVENTION
 SURGICAL INTERVENTION
Principles of Urinary fistula management
CONSERVATIVE MANAGEMENT

 Indications
Simple fistulae – less than 1cm in size
Diagnosed within 7 days of index surgery
Unrelated to carcinoma of radiation
 Continuous bladder drainage
By transurethral or suprapubic catheter
Duration upto – 30 days
- Small fistula may resolve spontaneously
- If fistula decreases in size — drainage for additional 2-3 weeks
- If no improvement seen in 30 days – needs surgery
NON SURGICAL INTERVENTION

 ELECTROCAUTERY FULGRATION
Small sized fistula (pinhole openings)
Vaginal or cystoscopic route
Fulguration – foleys catheter placement for 2-3 weeks
 FIBRIN GLUE
Useful and safe for intractable fistula
 LASER WELDING with Nd YAG laser
Fulguration and transurethral catheter for 3 weeks
SURGICAL INTERVENTION – General

Principles
 When to repair ??

No consensus in the literature as to the definition

of “ Early “

• Waiting period of several months

• Reduce tissue edema
• Optimal pliability of the tissues
Timing of repair

Dictum is best time to repair fistula is at its first closure during index surgery

 Obstetric fistula - 3 months following delivery

 Surgical fistula - If recognised within 48 hours – immediate repair otherwise repaired

after 10-12 weeks

 Radiation fistula - repaired after 12 months

Pre operative counselling

 Prolonged postoperative urinary catheter drainage

 intra operative alteration in surgical plan
 use of interpositional flaps or grafts
Approaches for VVF repair

 Vaginal approach
Sims Marion technique
Latzko technique
Flap splitting method

 Abdominal approach
 Laparoscopic approach
 Robotic approach
Vaginal approach

 SIMS TECHNIQUE
Sims – In 1852
Complete excision of the fistulous scar tissue and tract
Usually for small tissue or residual fistula after repair
Disadvantages
o Large soft tissue defect
o Bleeding
o Chances of ureteric injury
Vaginal approach

 LATZKO TECHNIQUE
- 1914
- Isolation of the fistula tract from the surrounding vaginal epithelium
- Approximation of the vaginal epithelium over the isolated fistulous tract
- re approximation of vaginal wall as a second layer
 Advantages
• Minimal blood loss
• No need for ureteric re implantation
Vaginal approach

 VAGINAL FLAP REPAIR

Abdominal approach

 INDICATIONS
High inaccessible fistula
Multiple/ complex fistula
Involvement of uterus or bowel
Need for ureteral re implantation
Associated pelvic pathology
Abdominal approach

Trendelenburg – 1888

 O CONOR TECHNIQUE
- bladder opened vertically
- bivalved down to the level of VVF
- excision of tract
- separation of bladder from vagina
- repair of vagina and bladder
Laparoscopic approach

 Limitations
• Difficult pelvic anatomy
• Dense pelvic adhesions
• intracorporeal laparoscopic suturing
Robotic asssited

Melamud et al - 2005

 Advantages
• Three dimensional visualisation
• Wristed instrumentation reducing severe angulation
Steps to avoid complications

 Urethral catheterisation
 Adequate adhesiolysis
 Gentle dissection
 Tension free closure of vagina and bladder
 Stay midline
Postoperative Management

 Post operative urinary drainage is necessary

 Keep supra pubic and foleys for 10 – 14 days
 Antimicrobials
 Cystogram after 10 – 21 days
 If persistent leakage is noted, continue with drainage and repeat imaging after 2 – 3 weeks

If repair fails, local repair should be reattempted after 3 months

Discharge advice

 To pass urine frequently

 Avoid intercourse for atleast 3 months
 To defer pregnancy for atleast 1 year

 Successful repair should have abdominal delivery

Lessons that can be drawn …
“
A woman’s health is her capital

”
Thankyou