VESICO-VAGINAL FISTULA

 

VESICO-VAGINAL FISTULA

 

INTRODUCTION:

          Fistula is nothing but an abnormal free passage from cavity or inner organ to exterior or another organ.  Abnormal communication between the urinary and genital tract is called genitor – urinary fistula.  The commonest type of genitor urinary fistula is vesico – vaginal fistula.

 

I. Definition:

          It is the fistula between the bladder and upper half of the anterior vaginal wall.

 

II. Incidence:

          Its incidence is failing in the developing countries.

 

III. Site:

          The fistula occurs at any site from the anterior vaginal wall down to half of the anterior vaginal wall.

 

IV. Size:

          Size may vary from a pins head upto that of admitting two fingers through which bladder mucous membrane may prolapse.

 

V. Cause:

1.    Obstetrical

2.    Gynaecologica

3.    Congenital

 

1. Obstetrical

          In the developing countries, the obstetrical cause is about 80-905 of cases obstetrical cause due to.

a) Obstetric-Trauma:

          Obstetrical labour causing necrosis of bladder and vaginal wall on prolonged compression of the tissues between foetal head and bony pelvis.

b) Obstetric Operative Trauma:

          Ceasearen Section, episiotomy etc fistula develops immediately after delivery of the baby.

 

2. Gynaecological

a) Operative Injury:

          Likely to produce fistula includes operations like anterior calporrhaphy, abdominal hysterectomy for benign or malignant lesions or removal of gartners cyst.

 

b) Traumatic

          The anterior vaginal wall and the bladder may be injured following fall on a pointed object by a stick used for criminal abortion, following fracture of pelvic bones or due to retained and forgotten pessary.

 

c) Malignancy

          Advanced Carcinoma of the cervix, vagina or bladder may produce fistula

 

d) Radiation:

          Apart from the overdose or malapplication, it may occur even with accurate therapy.  It takes usually long time (1-2 years) to produce fistula.

 

e) Infective

          Chronic granulomatous lesions such as vaginal tuberculosis, lympho-granuloma venerum, actinomycosis may produce fistula.

 

VI. TYPES

          Depending upon the site of the fistula, it may be

1. Juxta-Cervical [Close to the cervix]

          The communication between the supratrigonal region of the bladder and vagina.

2. Mid Vaginal

          The communication between the base (trigone) of the bladder and vagina.

 

3. Juxta Urethral

          The communication between the neck of the bladder and vagina (may involve the upper urethra as well).

 

VII. Clinical features

1. Patient history

          The patient are usually young primiparous with the history of difficult labour or instrumental delivery in recent past.

2. Symptoms:

a. Continuous escape of urine per vagina

b.  There is an associated pruritis vulva

3. Signs

a) Vulval inspection

·        Escape of watery discharge per vaginam of ammoniacal smell is characteristic.

·        Evidence of sudden and excoriation of the vulval skin.

·        Varying degrees of perineal tear may be present

 

b) Internal Examination

          If the fistula is big enough, its position, size and tissues at the margins are to be noted.

 

c) Speculum Examination

          Associated clinical features that may be present are;-

·        Secondayr amenorrhoea of hypothalamic origin.

·        Foot drop due to prolonged compression of the sacral nerve roots by the fetal head during labour.

·        Complete perineal tear or recto vaginal fistula.

 

VIII. Diagnosis

          The diagnosis is often made from the

1.    Typical history

2.    Local examination

 

Confirmation of diagnosis made by

1.       EUA [Evaluation under Anesthesia] is needed for letter evaluation.

2.       Dye Test

3.       Three Swab test

4.       Cystoscopy

5.       A metal catheter passed through the external urethral meatus into the bladder when comes out through the fistula confirms the vescico – vaginal fistula.

 

 

IX. TREATMENT

1.       Preventive

2.       Curative

 

1. Preventive

·        Adequate antenatal care is to be extended to risk mothers.

·        Early diagnosis of Carcinoma

·        Continues bladder drainage for a variable period of about 5-7 days following delivery.

·        Care to be taken to avoid injury to the bladder during pelvic surgery

2. Curative Treatment

·        Bladder drainage by a catheter for about 10-14 days.

·        Semi prone position

·        Alkali mixture

·        Chemotherapy and antibiotics

b) Surgical Treatment

·        Local repairs of VVF by flap splitting method routes of approach

a)   Vaginal Flap splitting method

b)   Transvisical

c)    Transperitoneal

X. Nursing Management

·        Increase the fluid intake of the mother to reduce the chance of infection.

·        Perineal hygiene increases including cleansing the perineum every 4 hours, taking sits bath and changing pads frequently.

·        Avoid physical stress on repaired area and preventing infection.

·        A Foley’s or supra pubic catheters is used to clean the bladder.

·        Supporting nursing care is extremely important.

Pre-Operative Assessment

a)   Fistula status: Assessment is done regarding the size, number mobility and status of the margins of the fistula

b)   Uretheral involvement is assessed by introducing a metal catheters through external urethral meatus into the bladder.

c)    To ascertain the position of the ureteric opening in relation to a big fistula.

d)   Blood examination for heamoglobin percentage total and differential count of white celler, area, cretine etc.

Pre-operative preparation

·        Improvement of the general condition is essential prior to surgery.

·        Locate infection in the vulval skin.  Should be treated by application of blank ointment or glycerine.

·        Urinary infection should be corrected before surgery.

 

Post – Operative Care:

·        Urinary antiseptics: Plenty of fluids by mouth appropriate chemotherapy or antibiots are useful.

·        Bladder wash with lotion acriflavine 1 in 10,000 once daily beginning at 48 hours after the operation.

·        The catheter should be kept for about 10-14 days.

·        Before removal of catheters periodic clamping of the catheter is to be done to see any leakage of urine into the vagina

 

Advice during discharge

·        To pass urine more frequently

·        To avoid intercourse for at least 3 months

·        To defer pregnancy at least 3 years.

·        If conception occurs, report to the hospital and must have mandatory antenatal check up and hospital delivery.

·        Supplementary iron and vitamins to improve the health status.

 

XIII Complications

·        Ascending infection of the urinary tract

·        Invalidism

·        Bladder Stone

 

SUMMARY

 

          Vescio – vaginal fistula is the fistula between the bladder and upper half of the anterior vaginal wall.  The fistula may occur at any site from the anterior vaginal vault down to half way of the anterior vaginal wall.  The cause are classified into obstetrical and gynaecotogical  the treatment are preventive and curative.

 

RECTO – VAGINAL FISTULA

 

INTRODUCTION

          We all know that a holed bottle, leak.  Like wise in our body any opening between two organs will lead to the escape of contents from one organ to other.  An imperfect separation of the rectum from the urogenital sinus will lead to recto – vaginal fistula.